The history of mental health services and addiction treatment in Canada parallels the European and American experience. The delivery of mental health services has, for the most part, evolved differently from the provision of addiction treatment throughout the last century. This has led to the emergence of two distinct systems of care and support – one for individuals with mental illness and another for individuals suffering from addiction. It is only during the last decade that efforts have been encouraged to better integrate the two systems.
The mental health service system and the addiction treatment system have struggled to provide the most compassionate and responsive treatment possible, but both have been dogged by the problem of stigma which had a negative impact on their development. Arising out of widespread misunderstanding and broad misconceptions, individuals with mental illness were often labelled as “idiots”, “imbeciles” and “lunatics”, while addiction problems were perceived as a sign of personal weakness. In some cases, a punitive attitude, exemplified by a desire to remove individuals with mental illness and addiction from public sight, has hampered the delivery of appropriate services. Despite many advances in models of care, policies and legislation, negative perception and stigma still persist today (see Chapter 3, above).
Although dramatic improvements have been made in the past two decades in the delivery of mental health services and addiction treatment, the Committee concurs with numerous witnesses that neither area has gained sufficient public support or government funding to ensure that Canadians obtain the same quality of services as they do when they receive treatment for physical illnesses, such as cancer or heart disease.
This chapter provides a chronological overview of the development of mental health services and addiction treatment in Canada. Section 7.1 summarizes the evolving views of mental illness that, over the course of time, have influenced the approach taken in Canada. Section 7.2 provides an historical perspective of the development of the mental health service system in Canada. Section 7.3 briefly reviews the evolution of the addiction treatment system.
The care of people with mental and behavioural disorders has always reflected prevailing social values related to the social perception of mental illness.
[WHO, 2001, p. 49]
For many centuries, religious, spiritual or cultural beliefs dominated the way in which individuals with mental illness were treated and regarded by society. Psychiatry is a “young” science relative to other scientific disciplines.
Stein and Santos (1998) recount that 5,000 year old skulls have been found in Eastern Mediterranean and North African countries with openings in them of up to two centimetres in diameter. It is thought that these holes were made by sharp instruments and that the procedure, trephination, was performed for therapeutic reasons. Some individuals were believed to have a mental illness which, at the time, was assumed to be the result of having evil spirits in their heads. The purpose of trephination was to allow the evil spirits to be released.
In ancient Greece, individuals with severe mental illness were thought to be influenced by angry gods; they were undoubtedly abused. Those with relatively mild conditions remained free but were treated with contempt and humiliation. According to Prince (2003), the cultural values of ancient Greece were precursors to the modern stigma that is associated with mental illness.
In Europe, during the Middle Ages (5th to 16th century), people thought mental illness had supernatural causes and was associated with demonic or divine possession. The affected individual was either tortured, burned at the stake, hanged or decapitated to liberate the soul from demonic possession.
In the 17th and early 18th centuries, the dominant view was that mental illness was an impaired physical state self-inflicted through an excess of passion. This view did not encourage compassion or tolerance; rather, it was used to justify poor living conditions and the use of physical restraints in places of confinement. Some individuals were chained to walls or even kept in cages.
In the late 18th century, Philippe Pinel, a French physician, and William Tuke, an English layman, pioneered the belief that those who behaved in strange and unexplainable ways did so because they were mentally ill. Pinel reformed the Bicêtre and Salpêtrière hospitals in France; he unchained the inmates and related to them as reasonable individuals, providing decent living conditions and treating them with respect. Similarly, Tuke, guided by humanistic ideals, founded the York Retreat in England where individuals with mental illness were provided with decent living conditions, related to in a respectful manner, and were expected to work to the extent they could.
The approach developed by Pinel and Tuke became known as “moral treatment”. Its success, based on considering of individuals with mental illness to be medical patients, led to the building of many psychiatric institutions, once known as “lunatic asylums”, in European countries and the United States. In parallel, this period saw the field of psychiatry burgeon as a medical discipline.
In the 19th and 20th centuries, a more “scientific approach” to the treatment of mental illness was introduced. Attempts were made to explain mental illness as a result of disease and/or damage to the brain, or as the sequella of congenital and hereditary defects. Because damaged, devitalized brain tissue cannot be renewed and little can be done to correct inherited constitutional defects, this new “scientific” approach led to an era of pessimism regarding the possibility of treatment.
It only dawned on people that a rational, even scientific, psychological treatment of mental illness was possible dawned only when thousands of World War I “shell shock” casualties demonstrated poignantly that everyone is vulnerable to psychological, social and physical stress and has a breaking point. This realization led to the development of modern psychiatry and clinical psychology.
The evolution of mental health service delivery in Canada, as in other developed countries, has been marked by three distinct periods, beginning with a moral or humanitarian approach to treating mental illness, followed by institutionalization and, finally, deinstitutionalization.
Prior to Confederation, many individuals who suffered from mental illness were either jailed or cared for within the family home or by religious bodies. At that time, few physicians practised psychiatry in either Upper or Lower Canada. There were even some who held that it was a waste of time to attempt any kind of treatment, either medical or psychological, for individuals with mental illness; they were considered incurable, non-functioning members of society. The treatment of individuals with mental illness, then, was mostly custodial.
In the late 19th century, both Upper and Lower Canada borrowed from the European experience and developed a number of small institutions that patterned themselves after the Tuke and Pinel approaches to provide patients the benefit of moral or humanitarian treatment. Initially, however, there were insufficient moral hospitals to accommodate all who needed them. Many individuals with mental illness remained locked in a room in their homes, or were incarcerated with common criminals.
The success of moral treatment led eventually to the building of numerous large asylums across the country. Thus began the process of institutionalization for individuals with mental illness. Initially, the patient-to-staff ratio was sufficient to provide moral treatment and decent living conditions, but, for reasons explained below, most of these institutions were unable to sustain the success rate of the dedicated pioneers of moral treatment.
Following European and American experience, lunatic asylums proliferated
across Canada 
These large institutions were usually self-contained and located in very isolated areas. Many individuals with mental illnesses, once admitted, would spend the rest of their lives there. Some patients were admitted involuntarily using legal processes and were retained in locked wards. Treatment attempted to incorporate work through occupational or industrial therapy (which gave patients small amounts of remuneration), together with recreational and social activities. Relationships between the staff and patients were marked by paternalism. Most patients remained isolated from their families and communities.
Many psychiatric treatments common in use in this period – hydrotherapy, insulin coma, crude psychosurgery (namely lobotomy) – have since fallen into disfavour or been abandoned as unethical or scientifically invalid. Electroconvulsive therapy (or ECT), given initially without general anaesthetics or muscle relaxants, was a commonly used but controversial treatment. The convulsions accompanying ECT often caused serious complications – seizures that lasted longer than expected, increased blood pressure, changes in heart rhythm, and compression fractures of the spine. Since then, ECT, while still the subject of controversy in some circles, has been widely recognized and endorsed by psychiatry and medicine generally as a safe and effective treatment for schizophrenia, severe depression and extreme mania. The lack of effective treatments for patients with mental illness is generally acknowledged to have significantly contributed to the relatively low esteem in which psychiatry was held throughout this period.
It should be noted that, during the process of institutionalization, efforts were made to promote mental health and de-stigmatize mental illness. For example, in 1948, the federal government established the Dominion Mental Health Grants to improve training and services. Funds from this source also led to the development of public awareness campaigns to promote the mental health of infants and children. “Mental Health Week” was designated in Canada for the first time in 1951. Similarly, during this period, the Canadian Mental Health Association fought to change the language used in legislation, and that also appeared in public discourse, that referred to individuals with mental illness as “idiots”, “imbeciles”, and “lunatics”.
After World War II, psychiatric institutions in Canada became overcrowded. In 1950, there were some 66,000 patients in psychiatric hospitals in Canada; they outnumbered patients in non-psychiatric hospitals. Most psychiatric institutions operated at more than 100% capacity. Understaffing, overcrowding and the lack of effective treatments led to an emphasis on custody rather than therapy. Contrary to the initial intent of moral treatment, institutional care became primitive and restrictive, relying on methods involving seclusion, as well as on chemical and physical restraints. All these negative consequences contributed to the process of deinstitutionalization described in the following section.
(…) deinstitutionalization is not merely the administrative discharge of patients. It is a complex process in which de-hospitalization should lead to the implementation of a network of alternatives outside mental hospitals. In many developed countries, unfortunately, deinstitutionalization was not accompanied by the development of appropriate community services. (…) It has become increasingly clear that if adequate funding and human resources for the establishment of alternative community-based services do not accompany deinstitutionalization, people with mental disorders may have access to fewer mental health services and existing services may be stretched beyond capacity. (WHO, 2003, p. 18)
A number of factors encouraged the trend towards deinstitutionalization. First, as a result of overcrowding and understaffing, many psychiatric institutions were seen as non-therapeutic environments wherein individuals were thought to be housed and dealt with in an inhumane, custodial fashion. Second, numerous studies in Canada, Europe and the United States highlighted the negative impact of long term institutionalization on the well-being of individuals with mental illness. These included: indifference, apathy, passive obedience, self-neglect and, sometimes, aggressive behaviour, as well as substantial loss of social abilities, increased dependence and added chronic physical illness resulting from isolation, in addition to authoritarian relationships between staff and patients. Third, with the advent of chlorpromazine – an effective medication that controls psychosis and severe mood disorders – and other neuroleptic medications came the hope that “cures” for severe and persistent mental illnesses such as schizophrenia were on the horizon (it is interesting to note that these early research findings stimulated considerable research interests in psychopharmacology and neuroscience in Canada). At the very least, it was expected that with these new medications individuals with mental illness could live comfortable lives outside of hospitals, allowing them to resume the functions of everyday life without constant supervision and care. And fourth, financial incentives that were offered to provincial governments through federal-provincial cost-sharing arrangements to fund psychiatric units in general hospitals proved hard to resist.
Two important national reports, along with the reports of several provincial commissions, highlighted these observations and encouraged the shift toward deinstitutionalization. In 1963, the National Scientific Planning Council of the Canadian Mental Health Association released More for the Mind which insisted that mental illness should be dealt within the same organizational, administrative and professional framework as physical illness. It recommended that psychiatric services be integrated with the physical and professional resources of the rest of the health care system.
Similarly, in 1964, the Royal Commission on Health Services, chaired by Emmett Hall stated: “Any distinction in the care of physically and mentally ill individuals should be eschewed as unscientific for all time”. The Hall Commission recommended that patients capable of receiving care in general hospital psychiatric units should be moved from psychiatric hospitals with all due speed. It was expected that patients would occupy beds in psychiatric units of general hospitals for brief periods of time during episodes of illness, but otherwise would live successful and satisfying lives in their communities.
Thus, in the 1960s the process of deinstitutionalization began. It was a long journey. Indeed, the deinstitutionalization process itself can be described in three distinctive phases covering the period beginning in the early 1960s and continuing to the present. The first phase (section 220.127.116.11) involved a shift from care in psychiatric institutions to care in the psychiatric units of general hospitals. The second phase (section 18.104.22.168) focussed on the need to expand mental health care into the community and to provide necessary community supports for individuals with mental illness and their families. In the third and current phase (section 22.214.171.124), the emphasis is on integrating the various mental health services and supports available within communities and enhancing their effectiveness.
Deinstitutionalization (…) evolved as a natural phenomenon following the advent of new pharmacological treatment, with the first era of anti-psychotic medication. Patients who spent years in institutions could now be treated with effective medications and their conditions often improved to the point that they could re-enter the community. In following years, deinstitutionalization became a desirable goal. In the beginning of community psychiatry, it was thought that behavioural problems of many chronic patients were secondary to some form of “institutional neurosis”. By taking steps to remove these patients from a pathological milieu and rehabilitating them in the society, it was hoped that social reinsertion would be successful for a large number of them.
[Dr. Dominique Bourget, Forensic Psychiatrist,
Hospital, Brief to the Committee, June 2003, pp. 2-3.]
The first phase of the deinstitutionalization process involved discharging large numbers of long-term stay individuals from psychiatric hospitals both into the psychiatric units of general hospitals and directly into relatively unprepared communities. This resulted, during the 1960s, in the closing of several of Canada’s larger, more isolated institutions. Long term hospitalization was slowly being replaced by shorter, intermittent stays. From 1960 to 1970, the number of patient days in psychiatric institutions was cut in half. The bed capacity of psychiatric hospitals decreased from approximately four beds per 1,000 population in 1964 to less than one bed per 1,000 in 1979.
It was intended that this shift from psychiatric institutions to general hospitals’ psychiatric units would have a significant impact, in particular by lessening the stigma associated with mental illness and psychiatry, as these illnesses and the practitioners who treated them became more closely integrated with the rest of medicine.
Initially, both general hospitals and psychiatric institutions resisted the placement of psychiatric patients in general hospitals; some general hospitals did not want psychiatric patients, while some psychiatric institutions worried that their resources were being dramatically reduced. However, there were benefits to shifting care to general hospitals. The general hospital units had the potential to enable early identification, to facilitate preventive psychiatry, and to treat a wide range of less serious psychiatric disorders.
Unfortunately, the psychiatric units of general hospitals did not adequately serve the patient population discharged from the former psychiatric institutions. On the one hand, human and financial resources were not reallocated to general hospitals as individuals were discharged from psychiatric institutions. Indeed, studies in the late 1970s showed that individuals with severe and persistent mental illnesses who were treated in the psychiatric units of general hospitals benefited from far fewer resources than had been available in the psychiatric institutions in which they accommodated.
On the other hand, general hospital psychiatric units tended to be used on a voluntary basis by middle and upper income individuals who were referred to them by private psychiatrists, while psychiatric institutions continued to provide services to poorer individuals and to those who had been admitted involuntarily. This, in effect, created a two-tiered system of mental health care: the general hospitals and psychiatric institutions served groups of patients that rarely overlapped.
Most importantly, the closing or downsizing of psychiatric institutions was achieved without providing adequate funding at the community level to provide for psychological support and rehabilitation outside the hospital. Thus, communities were left ill-prepared to provide discharged patients with appropriate support. Many individuals, disabled by persistent psychiatric illnesses, were left merely to subsist in the community. Although now living in a less restrictive environment, they received dramatically fewer services and less care if any care at all. According to numerous witnesses, this is a critical lesson that should never be forgotten in any movement to reform the mental health system.
The lack of proper services and supports in the community for those suffering from mental illnesses resulted in:
a high frequency of relapse (back to the psychotic state) and, therefore, increased readmission rates to hospitals;
the “revolving door syndrome”, where patients, after readmission to the hospital and treatment, were discharged back to inadequate care in the community, only to become ill again and start the process all over again;
increased criminal behaviour and incarceration (sometimes for minor crimes).
This situation was tragic for individuals with mental illnesses and their families. Some experts came to believe that the deinstitutionalization policy itself was a major mistake. They came to believe that patients would be better off if they lived their lives in institutions. By and large, however, most experts, including individuals afflicted with mental illness, did not agree. They resisted joining the chorus for massive re-institutionalization and advocated the provision of long term services and supports for everyday needs so that they could live stable lives in the communities.
In this second phase of deinstitutionalization, the shift from institutional to community care continued with an emphasis not only on community mental health care per se, but also on community mental health supports.
In this phase, provincial governments began to fund mental health services outside the hospital setting, mainly in response to deficiencies in the general hospitals’ psychiatric units. These services were provided by community mental health clinics. In addition, this phase also focussed on the need for an extensive array of community supports and services (such as residential services, vocational rehabilitation programs, and income support) to maintain individuals with mental illness, particularly those with serious and persistent illnesses, in the community. People believed that a more balanced approach was needed in the allocation of funding for mental health services between expensive, facility-based, treatment-oriented care and community mental health care and support. Case management was needed to ensure the coordination of services in a community-based delivery system.
During this phase, proponents of community care were pitted against facility-based providers, and hospitals were seen to be part of the problem rather than part of the solution. Also, the interests of professionals were sometimes seen to be divergent both from those of individuals with mental illnesses and their families. Increasingly, provincial governments became less responsive to the advice of professionals and more responsive to the voice of individuals with mental illnesses and family members. Nongovernmental organizations, in particular, became especially strong and effective during this phase; pressure on governments to provide housing, income support, and opportunities for socialization matched the pressure that was exerted by professionals to secure treatment.
The 1970s and 1980s were also marked by advances in biological psychiatry, which showed that abnormal neurotransmitter systems may underpin at least some mental illness. Research in this area of psychiatry was also key in explaining the effectiveness of psychotropic medications. During this period, research done in Canada contributed significantly, both nationally and internationally, not only to expanding knowledge about the brain functions, but also to developing new drugs and to the better therapeutic management of mental disorders. These years were also marked by major contributions from Canadian scientists in the field of genetics and mental disorders, such as schizophrenia and bipolar disorder.
By the end of the 1980s, mental health services and supports, although they existed in most provinces, were not well integrated. Indeed, it was often said that these were “three solitudes” – psychiatric hospitals, psychiatric units in general hospitals and community mental health clinics, supports and services.
As in the previous phase, it was recognized that there was a need for more community mental service interventions, including more home visits, outreach services, mobile crisis mental health teams, as well as better partnerships with self-help groups, and more assertive community treatment (ACT) teams, etc. But in this third phase of the deinstitutionalization process, individuals with mental illness and their families, through various nongovernmental organizations, continued to pressure governments to provide more and better community supports in various areas such as housing, income support, employment opportunities, etc.
In contrast with the previous phase, however, this third phase has been marked by an emphasis on empirical research. In fact, there is an important trend toward the adoption of the “best practice” framework by policy makers, professionals, individuals with mental illness and family members. It is believed that the evidence-based approach will lead to a much greater degree of cooperation and collaboration in facilitating mental health reform. Hospitals (both general hospitals and psychiatric institutions) are no longer seen to be outside evolving systems of comprehensive care; rather, they are regarded as essential components even though they may require a rethinking of their key functions and mechanisms in order to better link facility and community-based care. This third and current phase is thus characterized by a greater degree of inclusiveness in planning and implementation activities as well as by a much clearer consensus on the reforms that are needed.
In many provinces, the preferred model of mental health service delivery currently includes a broad range of coordinated community services operating in conjunction with the psychiatric units in general hospitals and an associated regional tertiary mental health care centre.
Major challenges remain, however. Simply put, mental illness has a social dimension that is not exhausted by the health care sphere. As those in larger cities are aware, the number of homeless people is increasing. As well, forensic psychiatry programs are under ever-increasing pressure for space. In addition, Canada is a multicultural society and mental health services and supports must accordingly be provided in a culturally appropriate manner. Perhaps most importantly, the many and changing needs of children, adolescents and transitional-aged youth suffering from mental illnesses – the “orphans’ orphan” – require major collaborative cross-sectoral action from the still poorly coordinated mental health, health care, social services, education, correctional, recreational, vocational and addiction systems.
The development of addiction treatment in Canada has been characterized by five (5) distinct phases. The first phase, ending in the late 1940s, was dominated by moralistic attitudes and a general lack of attention to treatment. Some addiction treatment was available in private asylums and some counselling services were established in prisons. However, most individuals with addiction problems (either with alcohol or other drugs) had little access to treatment services. The dominant view was that these problems resulted from a “lack of will power” or from “personality defects”.
The second phase, ending in the mid-1960s, was marked by a change in attitudes towards alcoholism and, to a lesser extent, towards problems involving other drugs. A major influence during this period was the growth of Alcoholics Anonymous (AA). AA promoted the view that alcoholism, although incurable, could be arrested if treatment was provided for withdrawal and the alcoholic followed a 12-step recovery program. With the support of some community leaders, AA members lobbied successfully for government-sponsored treatment and education programs. Efforts to secure government support for alcoholism services were also spurred by the view of alcoholism as a preventable and treatable “disease” rather than an expression or sequella of moral weakness.
During this phase, most provinces established departments, commissions or foundations to provide or coordinate addiction treatment services; many new services established. Initially, these agencies were principally concerned with alcohol-related problems but later, as individuals with addiction to other drugs began to increase in number, their mandates were expanded to encompass problems involving other drugs. It is important to note, however, that treatment for individuals who used illegal drugs took place in the shadow of a strong punitive approach to dealing with drug addiction.
The third phase began in the mid-1960s. It accompanied a surge in drug use and was characterized by a rapid expansion of addiction services. The most rapid growth occurred between 1970 and 1976. Of approximately 340 specialized agencies operating in 1976, two-thirds were established after 1970; expenditures on treatment services increased from $14 million to $70 million during the same period. The range of services established during this period included detoxification centres, outpatient programs, short- and long-term residential facilities and aftercare services. Some services for individuals with problems involving drugs other than alcohol were provided by programs established primarily to serve those with alcohol problems, but some specialized “drug” treatment services were also established during this period, including a number of therapeutic communities. Throughout this period, individuals in treatment were increasingly found to have been abusing other drugs simultaneously with alcohol.
The fourth phase began during the 1980s. It featured the relative autonomy of the provincial foundations and commissions within their respective health and social service systems. In many cases, addiction research, education and treatment occurred in systems that paralleled but were far from fully integrated with the general community health and social services systems. Despite this, there was a growing appreciation for the role of non-specialized health and social services in identifying and supporting specialized substance abuse treatment services.
This phase can also be characterized by the diversification and specialization of alcohol and drug treatment services, and with growth in special services particularly for women, adolescents and Aboriginal peoples. This trend was driven by research indicating that individuals respond differently to different types of treatment and by a growing belief that treatment should be adjusted for different populations and types of addiction problems. While various modifications of the medical model of treatment were prevalent across the country, a number of other treatments based on cognitive, behavioural and social theories and research also emerged during this period, an approach that has come to be known as the cognitive-behavioural (CB) model. Canada’s Drug Strategy, conceived as a multi-sectoral partnership, was launched in 1987. It helped stimulate a range of activity, including support for innovative treatment and rehabilitation services across the country.
The fifth and current phase, which began in the early 1990s, has been fuelled by dramatic changes in the structure of health service delivery across the country. Within a general environment fostering health care reform, most government addiction services have been integrated into community health and social services delivery systems. During this phase, there has been increased awareness of the need to better integrate alcohol and drug services, not only into the mental health service system, but also into larger social welfare policy and social support systems. Such integration of services is the result of the adoption of a population health approach in all provinces and territories. The holistic population health model emphasizes a complex set of health determinants – social, economic, cultural and environmental conditions, including behavioural choices – that impact both psychological status and biological states.
During this phase, new breeds of more potent drugs have emerged, putting young children and adolescents are at risk of addiction earlier than ever before. In addition, with the recent proliferation of gambling opportunities available to Canadians, problem gambling is an emerging concern in the field of addiction in many provinces and territories. Moreover, as corporate interest in addiction increases, the number of referrals from business and industry to Canadian addiction treatment services is growing.
Policies, programs and legislation in the fields of mental health, mental illness and addiction are the responsibility of both provincial/territorial jurisdictions and the federal government and involve numerous departments and agencies. The organization, governance, funding and delivery of mental health services and supports and addiction treatment in Canada are primarily the responsibility of provincial and territorial governments. Provinces and territories also govern mental health legislation in their respective jurisdictions.
The federal government has a direct responsibility for the delivery of mental health services and addiction treatment to: Status Indians and Inuit; the military; veterans; civil aviation personnel; the RCMP; inmates in federal penitentiaries; arriving immigrants; and federal public servants. The federal government also has various responsibilities, such as health promotion and disease prevention; disease surveillance; health research; human rights; drug approval; employment and disability benefits; etc. which have direct or indirect implications for the provision of mental health services and supports and addiction treatment in the provinces and territories.
The purpose of this chapter is to provide a general overview of the role and responsibilities of provincial and territorial governments with respect to mental health, mental illness and addiction. The role of the federal government in the field of mental health, mental illness and addiction is discussed in detail in a subsequent chapter.
Section 8.1 briefly describes and compares the organizational structure and level of integration of the mental health services and addiction treatment system in selected provinces – Alberta, British Columbia, Nova Scotia, Ontario and Québec; it also provides some information on recent reforms. Section 8.2 identifies a number of problems related to the provincial/territorial systems arising out of the testimony received by the Committee. Section 8.3 examines the mental health acts of all Canadian jurisdictions and highlights the major differences among them. Section 8.4 present the Committee’s commentary.
8.1 PROVINCIAL SYSTEMS OF
MENTAL HEALTH SERVICES AND ADDICTION TREATMENT
The Ministry of Health and Wellness has responsibility for overall policy development, implementation, funding, service planning and evaluation in the fields of mental illness and addiction. Responsibility for the provision of community-based and facility-based mental health services is split between nine regional health authorities (RHAs) and the Alberta Mental Health Board. Provision of addiction treatment is the responsibility of the Alberta Alcohol and Drug Abuse Commission (AADAC).
Since the beginning of April 2003, the delivery of mental health services and the management of Alberta’s four mental health facilities are the responsibility of the nine RHAs. Service delivery in the province encompasses Aboriginal mental health and reflects a strong integrated care/case management orientation. In other words, the vast majority of provision of front-line clinical services is under the direction of the RHAs and is integrated with the provision of physical health services.
The Alberta Mental Health Board, a provincial health authority accountable to the Minister of Health and Wellness, governs and operates province-wide services and programs such as forensic psychiatry, suicide prevention, tele-mental health (video-conferencing) and promotion activities. The Board also advises the Minister of Health and Wellness on matters related to the integration and performance of the provincial mental health system.
AADAC is a Crown agency accountable to the Minister of Health and Wellness. It is mandated to operate and fund services addressing alcohol, other drug and gambling problems (such as detoxification, residential treatment services; prevention, education, counselling), and to conduct related research. The Commission offers hospital-based addiction services in all regions. AADAC is also responsible for coordinating the implementation of the Alberta Tobacco Reduction Strategy.
RHAs, the Alberta Mental Health Board and AADAC work in partnership with the Ministry of Health and Wellness and other ministries and agencies in the implementation of the province-wide Children’s Mental Health Initiative (July 2001). This Initiative focuses on reducing the risk of mental health problems and substance abuse and on providing support and treatment for children, adolescents and their families.
In British Columbia, responsibility for policy development, implementation, funding, service planning, monitoring and evaluation in the fields of mental illness and addiction rests essentially with the Ministry of Health Services and the Ministry of State for Mental Health and Addiction Services. Responsibility for mental health policy for children and adolescents belongs to the Ministry for Children and Family Development which works in collaboration with the Ministry of Health Services and the Ministry of State for Mental Health and Addiction Services.
Governance, management and delivery of mental health services and addiction treatment, including community-based services, are the responsibility of RHAs which operate in 5 defined geographic areas. Core mental health and addiction services provided by the RHAs, with the assistance of the Ministry of Health Services, include: emergency response and short-term intervention services; intensive case management; outreach services; clinical services (assessment, diagnosis, treatment and consultation); addiction treatment (since 2002), preventive measures (research, education, early identification and intervention); psychosocial rehabilitation; case management and social supports, including respite care for family caregivers; residential services; and, when required, assistance in accessing housing, income assistance and rehabilitation services and benefits.
British Columbia has one large long-stay psychiatric hospital, Riverview Hospital, six community forensic psychiatric clinics and a Forensic Psychiatric Services Commission. RHAs are responsible for the community forensic psychiatric clinics. The Provincial Health Services Authority, the sixth health authority of the province, administers services provided province-wide by the Riverview Hospital and the Forensic Psychiatric Services Commission.
The Forensic Psychiatric Services Commission is a multi-site organization that provides specialized hospital and community-based assessment, treatment and clinical case management services for adults with mental illnesses and substance use disorders who are in conflict with the law. This unique, single-entry service ensures that forensic psychiatric clients have equitable access to mental health and addiction services throughout British Columbia.
The position of a provincial ministry of state responsible for mental health and addiction services in British Columbia is unique in Canada. It suggests strong recognition by the provincial government of mental illness and addiction as a serious public policy concern:
A unique approach has recently been implemented in
British Columbia with the establishment of a Minister of State for Mental Health. This appears to be a direct acknowledgment of the importance of mental health issues within society and provides prominent office, with a seat in cabinet, to oversee governance and administration of the provincial mental health system.
British Columbia has tried to implement best practices in mental health care. This has translated into the development of regionally integrated mental health services, with tertiary care provided in smaller, community-based facilities.
In recent years, British Columbia has established an addiction planning framework (May 2004), a child and adolescent mental health plan (February 2003), a depression strategy (October 2002) and an anxiety disorders strategy (April 2002). These province-wide initiatives are aimed at improving the quality and effectiveness of prevention, early detection/intervention, treatment and supports to individuals with mental illness and addiction.
The Department of Health is responsible for the planning, organization, funding, management, monitoring and evaluation of mental health services and addiction treatment. These functions are achieved mainly through the Mental Health Services Section and the Drug Dependency Services of the Department of Health. The nine RHAs (called “District Health Authorities”) are responsible for the provision of mental health services and addiction treatment (alcohol, tobacco, drugs, gambling) in their respective geographic areas.
The Provincial Forensic Psychiatric Service, also administered by the Department of Health, provides inpatient treatment and assessment, and a few community support programs. All inpatient forensic psychiatric services are located in a single institution - the Nova Scotia Hospital.
The IWK Grace Health Centre is an academic health sciences centre affiliated with Dalhousie University. The IWK operates the provincial child and adolescent psychiatry unit, some outpatient clinics and telemedicine consultation services.
Nova Scotia was the first province to introduce, in 2003, formal standards for mental health service delivery. These standards were developed through collaborative efforts involving individuals with mental illness and addiction, their families, community groups and the Mental Health Services Section of the Department of Health. It has been argued that more funding is needed to implement these standards province wide.
Responsibility for the planning, organization, funding, management, monitoring and delivery of mental health services and addiction treatment rests with the Ministry of Health and Long-Term Care (MOHLTC). In contrast to other provinces, there are no RHAs in Ontario. There are 16 District Health Councils, but their mandate is limited to advising the Minister of Health on the health matters and needs in their respective districts; they do not control funding of any service, including mental health and addiction services. As a consequence, the many mental health services, supports and addiction treatment providers function largely independently of one another.
The MOHLTC also coordinates the provincial forensic strategy in partnership with the Ministry of Community, Family and Children’s Services, the Ministry of the Attorney General, and the Ministry of Public Safety and Security.
The mental health and addiction treatment system in Ontario is currently in transition. In December 2002, 9 regional mental health implementation task forces released their reports on how to reform and renew the organization and delivery of mental health services and addiction treatment throughout the province. The main recommendation of these reports relates to the establishment of regional mental health authorities with responsibility for funding allocation and the delivery of mental health services and addiction treatment in their respective geographical areas. These regional systems would deliver a core basket of services and supports that would allow individuals to access a continuum of community-based services and supports where and when they need it. The Ontario government has not yet acted on the recommendations of these task forces.
The Ministère de la Santé et des Services Sociaux (MSSS) (Department of Health and Social Services) has responsibility for planning, organization, management, funding, monitoring and evaluation of mental health services and addiction treatment. The Minister for MSSS is guided in this responsibility by two distinct advisory bodies: the Comité de la santé mentale du Québec and the Comité permanent de lutte à la toxicomanie. The 18 RHAs are responsible for the provision of inpatient, outpatient and community mental health services and supports as well as addiction treatment in their respective regions.
The MSSS is responsible for implementing and coordinating the provincial action plan on addiction; the plan covers promotion, prevention, early detection and intervention, detoxification, social rehabilitation and reintegration. In addition, the MSSS coordinates Québec’s Strategy for Preventing Suicide. The purpose of this strategy is to consolidate and coordinate the various suicide prevention efforts to ensure equitable access to essential services in all regions. Essential services include: telephone hotline on a 24/7 basis; suicide crisis intervention (assessment, referral services, support services, monitoring); post-intervention (individual or group debriefing services for friends, relatives and caseworkers within 48 hours of a completed suicide). The strategy involves not only governmental departments, but also RHAs, CLSCs, hospitals, suicide prevention centres, police, schools, youth centres, community organizations, etc.
In two important aspects, British Columbia is unique in its approach to mental health and addiction policy in Canada. It alone has a minister of state responsible for mental health and addiction who can bring mental health issues to the forefront in Cabinet discussions. And second, only in British Columbia have the policy framework, governance and service delivery for both mental health and addiction been integrated.
In Alberta, Nova Scotia, Ontario and Québec, responsibility for mental health and addiction policy development and service planning rests with the provincial department of health. A number of provincial reports have noted, however, that policy development which impacts on individuals with mental illness and addiction has not been well coordinated across various social policy ministries. This has diminished the impact which would be derived from more thorough, consultative and inclusive inter-ministerial planning among the several ministries that must inevitably be involved in the provision of services to individuals with mental illness and addiction.
In all provinces but Ontario (which does not have RHAs as yet), programs and services to support individuals with mental illness and addiction are organized and provided by RHAs. Devolution through regionalization has facilitated the tailoring of services and supports to meet regional needs more closely. It has also facilitated collaboration among the various stakeholders involved in service delivery.
Reform of the mental health and addiction treatment system is occurring in most jurisdictions. While there are variations across provinces, a number of best practices criteria have been identified and largely agreed upon:
1. a shift from hospital to community-based services to create a more balanced approach to the delivery of mental health/addiction services;
2. specified, protected funding for an integrated mental health and addiction treatment system, including community, hospital-based and community-based tertiary care;
3. a single point of accountability where responsibility for the operation of an integrated system at the local/regional level;
4. mechanisms for the meaningful involvement of individuals with mental illness and addiction and communities in decision-making.
During its hearings, the Committee did not hear from individuals with mental illness and addiction or others about whether a particular province, region or RHA can be considered as a model to emulate in terms of policy development, organizational structure, governance and service delivery. Significant questions remain. For example, should the central authority for mental illness and addiction be at the provincial rather than at the regional level? Has any province or region been particularly successful at integrating hospitals and community services and supports? How can mental health services and supports best be integrated with addiction treatment? Has a particular province or region been able to coordinate mental health and addiction services with the broader social system (education, housing, justice, income support, etc.)?
The Committee heard repeatedly that the mental health and addiction system is not, in fact, a real system, but rather a complex array of services delivered through federal, provincial and municipal jurisdictions and private providers, including initiatives by individuals with mental illness/addiction themselves. This system is a mix of acute care services in general hospitals, specialized services for specific disorders or populations, outpatient community clinics, community-based services providing psychosocial supports (housing, employment, education, and crisis intervention) and private counselling, all of varying capacity and quality, often operating in silos, and all-too-frequently disconnected from the health care system. In most jurisdictions, there are limited if any ties between the “formal” mental health and addiction system and self-help initiatives that have taken root in communities nationwide. The result is, in most jurisdictions, a highly fragmented (non-) system that has become increasingly difficult to navigate by both individuals with mental illness and addiction and service providers.
Compounding this fragmentation is the fact that while mental health services/supports and addiction treatment are delivered by many different agencies, data information systems are not yet adequately linked across the sectors concerned (e.g. health, housing, education, family benefits, work environment, etc.). This makes it virtually impossible to monitor mental health services and addiction treatment other than those provided by hospitals or primary health care providers where some records are kept and can be accessed under the right circumstances.
The Committee was told that ensuring coordinated access to a broad continuum of services and supports is critical to the development of an effective strategy to address mental illness and addiction. This means that governments must invest in the community-based sector, as well as in hospitals and other institutions. Many witnesses stressed that a broad continuum of services and supports, including supportive housing and income supports, is key to meeting effectively the different needs of individuals at different stages of their illness and recovery; it is also key to ensuring a responsive mental health and addiction system capable of preventing acute episodes of illness, or of reducing their intensity or duration. Moreover, it is imperative that addiction be included in mental health reform initiatives.
A review of selected documents from a number of jurisdictions suggests that most provinces face very similar problems and challenges with respect to the current delivery of mental health services and addiction treatment. These problems and challenges are summarized below:
· First, as mentioned above, existing services and supports for individuals with mental illness and addiction are fragmented among many separate agencies and many access points. There is also the need to better integrate the mental health system with the health care system and the mental health system with the addiction treatment system.
· Second, the current mental health services system still reflects to a large extent an institutionally-driven philosophy of care; services and supports should be patient-centred and community-based.
· Third, the current mental health services system is not comprehensive; it does not provide the continuum of services and supports needed. As a result, individuals with mental illness and addiction often do not receive the services and supports they need when and where they need them.
· Fourth, historically, mental health services have been under-funded. This has been detrimental to those with severe and persistent mental disorders, particularly to those hardest to serve – individuals from different ethnocultural communities, people who are homeless, and those with concurrent disorders.
· Fifth, there are major human resource shortages in the mental health sector.
· Sixth, there is a significant lack of measures of accountability in the mental health services system. The roles and responsibilities of service providers are not clearly set out and an information system is needed to support the planning and operation of a more effective, comprehensive system and to monitor the effectiveness of the services it provides.
· And seventh, widespread stigma persists throughout society despite many efforts to educate the general public and the health care system as a whole. It has been said that stigma is the largest barrier to change in every level of the system.
Several witnesses stressed that recovery from mental disorders requires much more than what are considered traditional mental health services. For certain individuals, recovery may require – in addition to medication, therapy and case management – access to housing, transportation, employment and peer support. Yet, the various mental health systems have been slow to acknowledge and respond to these needs. In many provincial reports, reference is made to mental health services “and supports” to highlight the critical importance of each in providing the tools that an individual with a mental illness may need to recover from his/her illness, to overcome isolation, and to gain or regain economic self-sufficiency.
The lack of coordination among the various sectors, the absence of clear authority at the regional level and limited community-based supports have had tragic consequences for individuals and society. As pointed out in Chapter 5, a significant number of individuals with severe mental illnesses are homeless, living on the streets or in public shelters. In addition, a high proportion of incarcerated individuals have a mental disorder. Many of these individuals are jailed for non-violent misdemeanours, others for “crimes of survival” such as stealing food, loitering, or trespassing; their incarceration is often the result of their unmet needs for mental health services or addiction treatment and for housing.
Many witnesses pointed to the particular needs of children and adolescents. In fact, the system of child and adolescent mental health services and supports has been called by witnesses the “orphan’s orphan” of the health care system. Mental health services for children and adolescents at the provincial and territorial levels often involve a variety of departments and agencies (e.g., mental health, child welfare, young offender, addiction services, and special education services). There is general dissatisfaction in most jurisdictions with the present delivery of children and adolescents services. Information suggests that:
· The current system is highly fragmented; services are delivered in an uncoordinated fashion through multiple providers. The problems of children and adolescents do not come as neatly divided in terms of responsibility as government departments are.
· The prevalence of mental illnesses among children and adolescents far exceeds the capacity of the current service delivery system; there is a lack of access to needed services and there are long waiting lists for the limited services that are available.
· Mental health policies and programs have focussed largely on the treatment of the adult population; consequently, services for children and adolescents have developed slowly and only as an adjunct to programs for adults.
· There is insufficient funding for mental health services directed at children and adolescents.
· There is an urgent need to enhance preventive and early intervention services.
· Currently, many effective interventions are not made widely available to children and adolescents, and many ineffective interventions continue to be used even when shown to be more expensive and restrictive than available alternatives. Thus, there is a need to better incorporate research evidence about effective practices into decision making at all levels, including clinically.
· No clear goals and objectives have been set and few indicators of outcomes relevant to children and adolescents are reported on a regular basis to assess the performance and effectiveness of the system of mental health services.
· Nobody seems to be in charge, that is, there is no executive component with authority to cause the whole system of care to decide upon and implement coherent action.
· There are no external incentives for efficiency – surplus dollars must often be returned to central coffers rather than being reinvested locally.
Witnesses also raised a number of concerns with respect to the specific needs of individuals with concurrent disorders (mental illness and addiction). These individuals may access needed services and supports through various entry points, either within the mental health system or within the addiction treatment sector. However, numerous barriers affect the ability of these individuals to access and obtain appropriate treatment:
· The mental health and addiction systems often operate in parallel, a barrier to ensuring that a person receives treatment for both problems in an integrated fashion. Current services provided for this population are poorly linked, both within and between the addiction and mental health systems.
· There are no systematic approaches and effective assessment tools to better identify this population.
· Because of inappropriate identification, individuals fail to receive proper care or receive care for only one disorder (either substance use or mental illness) but not both.
· Many mental health programs exclude individuals with active substance abuse problems, and similarly, many addiction programs exclude individuals with mental health problems.
· Staff in both the mental health and addiction fields need cross-training to improve the identification of this client population and provide better treatment planning based on client needs.
· The fear/stigma associated with both mental illness and addiction often prevents individuals with concurrent disorders from seeking treatment and may lead to self-medication.
· Individuals with concurrent disorders and their families lack information on existing services and how they may be accessed.
Very similar concerns – such as fragmentation, the existence of silos, stigma, lack of specialized human resources, the need for early intervention and preventative measures – were expressed with respect to the mental health needs of senior Canadians and individuals in forensic psychiatry services.
While a higher proportion of individuals than ever will make a complete or significant recovery from their mental illness/addiction, the illness will continue to have a significant impact on aspects of the lives of many for long periods, even a life time. Once the initial symptoms have been diagnosed and controlled properly, individuals with mental illness and addiction need three broad types of services: relapse prevention, clinical services and rehabilitation/support services. All three elements require management; for an individual with mental illness and addiction, the process is called “case management”.
As explained in Chapter 4, case management refers to the continuing and ongoing support provided to individuals with mental illnesses/substance use disorders to assist them to obtain needed services. When the severity of an individual’s illness or the complexity of the system precludes the affected person from accessing the needed services him/herself, case management may be provided by clinical and support service staff. For individuals with multiple needs intensive case management is essential. While case management is highly regarded as a core function in the system, a number of different approaches to providing case management have been used.
Relapse prevention consists in helping individuals maintaining their recovery. The Committee was told that the most important component of relapse prevention is to ensure that the affected person continues to take his/her medication. Often, individuals stop taking their medication because they feel well and are no longer motivated to continue. They may also experience what they consider to be intolerable side effects and stop medication. In both cases, they then lose insight into the benefits of taking medication and suffer relapse of their illness. Once-a-day dosing and minimizing toxicity/side effects can help to reinforce patient compliance. However, education, counselling and regular monitoring are also vital to improve compliance. Witnesses told the Committee that developing standards and guidelines for relapse prevention measures, in consultation with health and educational authorities, is critical.
Clinical services are a core component of overall services and supports because many individuals do experience relapse. Even when they follow a treatment plan faithfully, many individuals can become severely ill and require acute treatment. For some, where safety or complexity is an issue, hospital admission is also necessary. Clinical services include inpatient services, hospital-based clinics, support groups, information sessions, outpatient clinics, mental health centres, visiting clinical teams, emergency teams and a variety of other clinical services located in community settings; all are necessary to meet the varying needs of individuals with mental illness. Such clinical services, together with NGOs, are needed to provide a full spectrum of care for affected individuals and their families. Coordinating such a complex system is essential. Again, the Committee was told that clinical guidelines or standards are essential to promote their effectiveness and efficiency.
Rehabilitation and ongoing support services must be available to help optimize the quality of life of affected individuals and help them recover their abilities to the fullest extent possible. These services include: housing, ranging from professionally staffed group homes to independent apartments with regular consultation and the availability of 24-hour 7-day crisis response; vocational services including job finding and support and skill training; social and recreational services including assisting people to join in normal community activities and “drop in” places; and income support, as many individuals have difficulty in obtaining and maintaining employment. All these services and more should contribute to ensuring the continuum of care of a seamless system.
The Committee was told that, as with other health services, mental health services and addiction treatment are especially lacking in rural and remote areas of the country, including most Aboriginal communities. In many such areas, there is no resident psychiatrist. The result is that individuals with mental disorders living in rural and remote regions and Aboriginal settings are forced to travel far from their homes to receive needed services. This hardship, ironically dubbed “Greyhound Therapy”, is doubly stressful for someone affected by mental illness and addiction.
When individuals must travel from their communities to access mental health and addiction services, they are separated from their natural support systems and informal care networks that provide the kind of financial, emotional and social supports for recovery that are not found in the formal system. Although for some the anonymity of the city is a welcome respite from the shame and stigma that usually affect individuals with mental illness and addiction in a small community, being removed from that community can also compromise treatment interventions and outcomes.
The Canadian Mental Health Association pointed out that rural and remote communities also experience particular mental health issues such as those triggered by drought, flood and other environmental disasters. Such communities may also be characterized by compounding factors, such as lower educational and income levels, higher adolescent birth rates, a higher proportion of unwed mothers, and higher unemployment rates, that can contribute to the development and exacerbation of mental health problems and illnesses. According to the Association, transplanting urban professional mental health workers into rural settings, even if they are willing to relocate, would not necessarily qualify or equip them to deal with the distinctive rural and cultural issues affecting their clients.
The primary health care sector is usually the first point of contact of individuals with mental illness and addiction with the health care system. Yet, the Committee heard repeatedly that many family physicians lack sufficient knowledge, skills and motivation to manage patients with mental illness and addiction, to accurately screen for mental disorders, or to navigate the appropriate referral pathways to access the more specialized mental health and addiction system. Dr. Sunil V. Patel, President of the Canadian Medical Association (CMA), told the Committee:
While family physicians can deal with a number of mental illnesses, most are not trained in the complicated medical management of severe mental illness. Many family physicians’ offices are also not sufficiently resourced to deal with family counselling, or related issues such as housing, educational and occupational problems often associated with mental illness.
Witnesses also told the Committee that many provincial health care insurance plans limit the amount of mental health services that can be billed by family physicians. For example, Patrick Storey, Chair of the Minister’s Advisory Board on Mental Health (British Columbia), stated:
Medical billing schedules and procedures, extended health benefits, pension plans, et cetera, do not recognize the special features and challenges of mental illness and create unnecessary obstacles to recovery and health. For example, in
British Columbia, a family doctor can bill for only four counselling sessions per patient per year; yet, most people with depression go to see their family doctor. Though antidepressant medication is a helpful adjunct, alone it is not sufficient to help people deal effectively with that sometimes debilitating condition. Doctors are not in a position to provide the help required for a person in a depression.
Dr. James Millar, Executive Director, Mental Health and Physician Services, Nova Scotia Department of Health, expressed similar view when he stated:
Even physician services are restricted. (…) Many provincial health plans restrict the number and types of mental health services that can be provided by general practitioners. In many cases, family practitioners are ill prepared to treat the serious mental disorders that appear [sic] in their offices. There is little support for education or on-site consultations.
Another concern brought to the attention of the Committee is that, currently, primary health care reform is occurring in relative isolation from the reform of the mental health and addiction system in communities across the country. Yet, many witnesses felt that these two systemic reforms ought to share the same goal of improving the provision of quality, accessible, comprehensive, integrated, timely services to all those who need them regardless of the type of underlying disease.
The Committee was told that progress could be made, however, with support for “shared mental health care” initiatives across the country. These initiatives, which stem from a partnership between the College of Family Physicians of Canada and the Canadian Psychiatric Association, appear to be a success story; they refer to collaborative activities between primary health care providers and psychiatrists. Some shared mental health care initiatives have a strong clinical focus and integrate mental health services within primary health care settings.
Irene Clarkson, Executive Director, Mental Health and Addictions, British Columbia Ministry of Health Services, stated that shared mental health care initiatives within primary heath care settings would help to enhance early detection and intervention:
Through primary health care 60% of persons with mental disorders and substance use disorders currently access their services in B.C., and therefore improved primary care is a priority for change. (…) Evidence in the medical literature supports the delivery of these interventions by multidisciplinary teams. (…) In many instances physicians are the only source of mental health and addictions services for people at risk or with mental disorders and substance use disorders, therefore, attention to primary care can promote early detection and intervention for mental health and addictions problems which in turn leads to better long-term prognosis; allows for teaching clients self-management of their health; and, ensures ongoing, periodic assessments and treatment to promote stability and community tenure.
Many witnesses felt that the federal government could play a major role in ensuring that successful shared care initiatives continue to be funded and that best practice models be implemented and converted into permanent programs and policies in all provinces and territories.
Like other areas in the health care system, mental health services and addiction treatment suffer from a lack of coordinated planning for its human resources. There is no central planning mechanism to coordinate hiring or to ensure the appropriate distribution of appropriately qualified and experienced service personnel across communities. The growing geographical concentration of mental health and addiction professionals in large urban centres is also a major concern.
Witnesses told the Committee that there are chronic shortages of providers, including of psychiatric nurses, psychiatrists, social workers, case managers and occupational therapists with knowledge of mental health and addiction issues.
The growing need for expert services is exacerbated by a shortage of psychiatrists and limited access to psychologists. According to the Canadian Psychiatric Association, the ideal psychiatrist to population ratio (1:8,400) is far from being achieved, especially outside urban centres. To compound the problem, an increasing number of the Canada’s 3,600 currently counted licensed psychiatrists are not working full time, particularly women and young graduates just entering the field who have made lifestyle choices to work fewer hours. Certain specialties are especially under-resourced, such as child, geriatric and forensic psychiatry. Individuals with concurrent disorders (mental illness and addiction) and dual diagnosis (mental disorder and developmental disability) have particularly limited access to appropriate psychiatric care. In addition, particular groups such as immigrants/refugees lack a level of services appropriate to meet their needs.
For psychological services, equality of access appears to be the major problem. Publicly funded psychology services through hospitals or mental health clinic programs are spotty and limited in their availability. As general hospitals face budgetary constraints, their departments of psychology are frequently reduced or eliminated. Moreover, many low- and middle-income individuals, together with people who are unemployed and/or those who do not have private health care insurance, cannot afford to pay for private psychological services which are not covered under publicly funded provincial health care insurance.
Long waiting lists and significant delays in diagnosis, treatment and support are direct by-products of a mental health system that lacks the human resources to deliver care effectively. While there are no standardized sources of data currently available for compiling national information on waiting lists, provincial estimates depict a pretty grim picture. The Canadian Mental Health Association stated in its brief that:
(…) about half of the adult population who need services must wait for eight weeks or more – an eternity in the lifetime of a person, a family or a community struggling with serious mental illness or addiction. For some individuals, having to wait for services is the difference between life and death. While the crisis in surgical waiting lists makes the headline news, society remains fairly oblivious to the suffering and isolation of those experiencing a mental health crisis who suffer and wait in silence for critical and medically necessary supports. It is most tragic that when a person finally finds the strength and courage to reach out for help, more often than not their first contact with the mental health system becomes a discussion of how long they must wait.
Dr. Cornelia Wieman, Psychiatrist from the Six Nations Mental Health Services (Ohsweken, Ontario) informed the Committee that currently there are only four Aboriginal psychiatrists in Canada. In her view, it is important, indeed critical, to train an increased number of Aboriginal health professionals. This would help ensure that services are provided in a more culturally appropriate manner and remove some of the barriers to those seeking mental health services in communities universally acknowledged to have particular need for them.
Many recommendations were suggested to the Committee with respect to the planning of human resources in mental health, mental illness and addiction. For example, it was recommended that the provinces and territories, in partnership with the federal government, develop a long term plan that will ensure high quality appropriately trained service providers – both professionals and para-professionals – to address the mental health needs of Canadians. This plan would include:
· a detailed national human resource plan for mental health and addiction personnel based on forecasted needs and projected trends;
· a compilation of information on waiting lists; development of national standards and guidelines for maximum waiting times across the full continuum of mental health care and addiction treatment services;
· review of the effective use of alternatives to professionals outside the medical field, such as home support workers, social workers, peer support workers and informal social networks to decrease the demand for psychiatrists;
· creation of a task force to review and make recommendations on how to improve the knowledge of and training in mental health intervention and promotion strategies as part of the curricula of training of all health professionals and of undergraduate and graduate students within the health disciplines, education, social work and other related programs at the university and college levels.
· analysis of the extent to which interdisciplinary opportunities for joint education (undergraduate, graduate and continuing education) could be used between physicians and psychologists, nurses, social workers, occupational therapists and addiction counsellors;
· incentives for the recruitment and retention of mental health professionals and students in these disciplines;
· a study of various models of mental health service delivery in rural areas, including the use of telehealth.
[The] problem of access occurs across the continuum of services from primary care for common disorders to urgent and crisis services for more severe and persistent disorders.
[Dr. Donald Addington, Professor and Head, Department of Psychiatry, University of Calgary, Brief to the Committee, 29 May 2003, p. 3.]
Despite efforts by provinces and territories to improve the delivery of mental health services/supports and addiction treatment, a majority of Canadians suffering from mental illness and addiction still do not seek and receive professional help. Statistics Canada’s Canadian Community Health Survey (CCHS), Cycle 1.2 on Mental Health and Well-Being, found that only 32% of those suffering from mental illnesses and substance use disorders saw or talked to a health professional during the 12 months prior to the survey. These professionals included either a psychiatrist, a family physician, a medical specialist, a psychologist or a nurse.
When individuals did see a health professional for mental illnesses or alcohol or drug use and abuse, family physicians were most often consulted. Nearly 26% of those individuals surveyed consulted a family physician; some 12% consulted a psychiatrist, and 8% a psychologist. About 10% saw or talked to a social worker.
The CCHS also showed that adolescents and young adults (15 to 24 years old) were the least likely of all age groups to use any resources for mental illness and addiction than other age groups, although they exhibited higher prevalence rates for mental disorders. Only 25% of affected adolescents and young adults reported having consulted a professional or using other assistance during the previous year.
In his submission to the Committee, Phil Upshall, President of the Canadian Alliance on Mental Illness and Mental Health, enumerated the various factors that lead to unmet needs in mental health services/supports and addiction treatment:
“Why do people not receive treatment and, most likely, the other services they require?
In part, it is due to a general lack of awareness in the Canadian population of mental illness, or a lack of understanding of the symptoms of mental illness.
Stigma stands in the way – the fear of having a mental disorder continues to be strong.
Services are scarce. Governments choose to make their health investments in narrowly defined biomedical services at the expense of services for the mentally ill and those with psychological complications in physical illness and disability.
Not all services are available to all Canadians. Only those with average to above average incomes can afford private practice services, and the mentally ill are often at the other end of the spectrum. They make up a disproportionately large percentage of marginalized populations – those without adequate income, housing or support systems to meet their basic needs.
On the part of the medical community, low awareness and understanding of the symptoms of mental illness, and time constraints come into play.”
Dr. Donald Addington, Professor and Head, Department of Psychiatry, University of Calgary, recommended the establishment of a patient charter that would establish standards for access to mental health services in primary health care, specialized mental health services and acute care.  In Ontario, the Champlain District Mental Health Implementation Task Force (2002) also recommended the creation of a “Provincial Mental Health Patients’ Charter of Rights”. The preamble of the proposed provincial patients’ charter of rights stated:
People living with mental illness are entitled to the full range of rights and privileges as citizens of Canada, including the right to health care, income maintenance, education, employment, safe and affordable housing, transportation, legal services, and equitable health and other insurance, and are not limited to the rights listed in this Charter.
This charter would not be limited to mental health services but would also encompass broader social supports. More precisely, the proposed charter included, for example:
· Mental heath services that are safe, secure, evidence-based, timely, culturally appropriate and relevant to the individual’s needs;
· Services and supports that encourage the involvement of individuals with mental illness and addiction and are based on the principles of recovery, self-help and independent living and functioning;
· Treatment that is respectful of relevant legislation (Mental Health Act, Canadian Charter of Rights and Freedoms, etc.);
· Respect for privacy and informed choices.
Other witnesses suggested some form of “mental health equitable act”, a piece of legislation intended to bridge the gap between physical illnesses and mental disorders in terms of public coverage and the services provided. Still, others supported the need for a “mental health advocate”, a contact person for individuals experiencing difficulty in accessing needed mental health services and supports. A mental health advocate existed for some time in British Columbia, but the position was eliminated when the Ministry of State for mental illness and addiction was created.
The high level of unmet needs in the field of mental illness and addiction underscores the importance of early detection and intervention. As a matter of fact, numerous witnesses stressed that early intervention – which encompasses detection, assessment, treatment and supports – can interrupt the negative course of many mental disorders and lessen long term disability. New understanding of the brain indicates that early detection and intervention can sharply improve outcomes and that long periods of abnormal thoughts and behaviour have cumulative effects that can limit a person’s capacity for recovery. For example, the Schizophrenia Society of Canada stated:
For most diseases, the earlier they are detected and treated the better the expected outcome is for the person affected by the illness. (…) Unfortunately, because of a lack of public and professional knowledge about the symptoms, stigma and denial of the illness, many people delay seeking treatment. It is estimated that half of the people with schizophrenia go for an average of about 2 years before they receive a diagnosis and treatment after first manifesting symptoms.
Research has shown that the longer the psychotic symptoms are left untreated the worse the long term prognosis. There is greater evidence of brain damage in persons who experience long, untreated psychotic episodes compared to those who experience shorter, more efficiently treated episodes. In addition to longer periods of non-treatment causing more evidence of brain damage, the person is more likely to lose employment or educational standing, lose friends and interpersonal skills, and is more likely to run afoul of the law due to the symptoms of the illness.
The benefits of early intervention extend to numerous mental illnesses and to individuals of all age groups. Without early intervention and treatment, child and adolescent disorders frequently continue into adulthood. If the system does not appropriately screen and treat them early, these childhood disorders are likely to persist and lead to a downward spiral of school failure, poor employment opportunities, and poverty in adulthood. No other set of illnesses damage so many children so seriously.
Currently, no agency or system is clearly responsible or accountable for children and adolescents suffering from mental disorders. They are invariably involved with more than one specialized service system, including mental health services, special education, child welfare, youth justice, addiction treatment, and health care.
Schools are where children spend most of each day. While schools are primarily concerned with education, good mental health is essential to learning as well as to social and emotional development. Because of this important interplay between mental health and academic success, schools should be partners in the mental health care of children.
Early intervention is also essential to reduce the pain and suffering of children, adolescents and adults who have concurrent disorders (mental illness and addiction). Too often, these individuals are treated for only one of the two – if they are treated at all. If one disorder remains untreated, both usually get worse and additional complications often arise, including the risk for other medical problems, unemployment, separation from families and friends, homelessness, incarceration, and suicide. The Committee was told that few providers or systems that treat mental illness or addiction adequately address the problem of concurrent disorders.
Early intervention should occur in readily accessible settings such as primary health care settings and schools and where a high level of risk for mental illness exists, such as youth justice and child welfare services. A coordinated approach is necessary together with training the school workforce to screen for and recognize early signs of mental illness; training primary health care providers; and eliminating barriers to publicly funded heath care insurance, particularly for psychology services.
In addition to their primary
responsibility for delivering mental health services and addiction treatment
within their jurisdiction, provinces and territories are responsible for
enacting mental health legislation. Such legislation governs the provision
of psychiatric treatment to individuals who are severely afflicted by mental
illness and who are unable to seek out and accept needed care. At the
present time, each province and territory has its own mental health act,
except Nunavut in which the Northwest Territories law applies.
All provincial and territorial
mental health legislation defines criteria for involuntary admission to
hospital for psychiatric treatment, treatment authorization and refusal,
conditional leave, and review and appeal procedures. Without compulsory
hospital admission and psychiatric treatment, individuals who will not
accept voluntary treatment are abandoned to the consequences of their
untreated illness. Individuals affected by untreated mental disorders have
a high mortality rate and higher lifetime disability rates than those
affected by most physical illnesses.
While compulsory treatment will usually restore
someone’s freedom of thought from a mind-controlling
illness and restore their liberty by releasing them
from detention, their feelings of autonomy and legal
and civil rights may be impacted.
For this reason, it is necessary for
legislation to balance all their needs and those of
society as a whole.
[Gray, Shone and Liddle (2000), Canadian Mental
Health Law and Policy, p. 5.]
Mental health legislation is also
meant to reflect a balance between the rights and dignity of the individual,
the protection of society, and society’s concern to help those not able to
help themselves. In fact, all provincial and territorial legislation must
comply with the Canadian Charter of Rights and Freedoms. The
pertinent sections of the Charter are sections 7, 9, 12, 15, as well
as section 1. Under section 7, an individual cannot be deprived of life,
liberty or security of the person unless that deprivation is in accordance
with the principles of fundamental justice; under section 9, a person is
guaranteed the right not to be arbitrarily detained or imprisoned; under
section 12, a person has the right not to be subjected to cruel and unusual
treatment or punishment; and, under section 15, every person is equal under
the law and has the right not to be discriminated against on the basis of
mental disability. Although the Charter guarantees certain rights
under the sections mentioned, a qualification under section 1 serves to
limit the absolute scope of those guarantees. Under section 1, Charter
rights are subject to reasonable, justifiable limits. Thus, a court may
decide that the violation of a right that is guaranteed under the Charter
is reasonable and therefore justified in today’s society.
In 1984, prompted by anticipation
that much of existing mental health legislation was susceptible to possible
challenge under the Charter, a “Uniform Mental Health Act” was
developed by a working group established under the Uniform Law Conference as
a model for provincial mental health legislation. The working group
consisted of a lawyer and a senior mental health official from each
participating province and territory. The Uniform Mental Health Act was
adopted by Uniform Law Conference representatives in 1987. The ensuing
principles form the essence of the proposed Uniform Mental Health Act:
A system that promotes
voluntary admission and treatment with informed consent is preferred to
· Where there is no alternative to involuntary detention and treatment which limit a person’s liberty or right to make decisions, these limitations must conform with the Charter;
· A range of appropriate treatment options, including the least restrictive and intrusive alternatives, are offered and explained to the person;
· The duty of confidentiality of information in the medical file/record is heightened by the vulnerability of mentally-ill persons and the potentially severe consequences of improper release of such information;
· The patient has the right to view, for purposes of accuracy, documents gathered for the purpose of his/her medical treatment;
· If a person’s rights and freedoms are affected by legislation, an independent body or a court can review the decision to determine whether or not the decision was reached fairly.
Although the Uniform Mental Health Act was never implemented as such in each province and territory, many jurisdictions have enacted legislation which conforms with its fundamental principles. There remain, however, significant differences in the provisions of the relevant mental health statutes among the various jurisdictions. These differences can have profound effects on individuals with severe mental illness, many of whom may not receive timely needed treatment. They can also create significant ethical dilemmas for psychiatrists. Gray and O’Reilly (2001) pointed to the following major disparities:
· In some jurisdictions, involuntary admission criteria stipulate that a person must be likely to cause serious physical harm to himself/herself or others (Alberta, Nova Scotia, Northwest Territories and Nunavut). In the other jurisdictions, the criteria for involuntary admission also include the potential of non-physical (mental) harm. The criterion which limits involuntary admission and treatment to physical harm raises ethical issues for psychiatrists, who may see a patient who is extremely distressed because of a psychotic illness but who is not likely to be dangerous (physically) to himself/herself or others. In such cases, while psychiatrists know that treatment would be quickly effective and would relieve suffering, they can neither hospitalize nor treat the affected person. As a result, some individuals with severe mental illness and in need of psychiatric treatment will not receive timely care. According to Gray, Shone and Liddle (2000): “The rise in the number of people with mental illness in prisons and homeless on the streets is blamed in part on laws restricting involuntary admission to the physically dangerous.”
Following involuntary admission, some jurisdictions do not allow the individual to refuse treatment (British Columbia, New Brunswick, Newfoundland, Québec and Saskatchewan); these provinces use an appointed officer of the state to authorize treatment (either the attending physician, the director of a psychiatric unit, a tribunal or the court). The other jurisdictions do allow a refusal, that may be overruled in the individual’s best interests by a substitute decision-maker (either a guardian, relative, public trustee, review board or court). Still, three other jurisdictions (Ontario, Northwest Territories and Nunavut) honour a previously expressed wish not to be treated, even if that prolongs detention and suffering. All jurisdictions provide for a board or panel to review the validity of involuntary hospitalization. When the process for obtaining treatment authorization involves a tribunal, the court or a substitute decision-maker, there may be delays lasting a few days, months or even years before treatment can be provided.
· All jurisdictions recognize that compulsory treatment in the community is a less restrictive option compared to involuntary admission and treatment in hospital. Accordingly, provincial/territorial mental health acts contain provisions that authorize conditional leave from hospital or community treatment orders (CTOs). The conditional leave provisions authorize an involuntary patient to be discharged in the community; the patient remains under the authority of the hospital but is continuing his/her treatment there. Under the CTO (Saskatchewan and Ontario), the individual is not an involuntary patient but is put on the order for the purpose of compulsory treatment while living in the community. CTOs are intended to reduce the “revolving door syndrome”, make hospital beds available to others and assist with integration into the community. For CTOs to be effective, however, the services and supports required to support the conditions must be available. A major criticism of CTOs is that the necessary services are not available out of hospital and, thus, individuals will fail in the community and be hospitalized. A similar criticism is that hospitals will prematurely discharge someone on leave and “dump” him/her on the community. Only four provincial mental health acts (British Columbia, Manitoba, Ontario and Saskatchewan) do not allow a person to be on CTO unless appropriate supports exist in the community.
It is clear that psychiatric management of individuals with severe episodes of mental illness differs greatly depending on where affected persons live in Canada. In some jurisdictions, where individuals with severe mental disorders are admitted to hospital and treatment starts promptly, there is a good chance for their returning to “normal” daily activities. In other jurisdictions, many months, if not years, may elapse before an individual’s mental health deteriorates to the point where he or she is deemed to be at risk of inflicting serious bodily harm on himself/herself or on others, sufficient to warrant involuntary hospitalization. Even when hospitalized, treatment may be delayed for months or years in jurisdictions in which its initiation is prevented while an appeal is outstanding or those concerned are bound by a previous, capable, applicable wish not to be treated.
In their review of provincial and territorial mental health legislation, Gray and O’Reilly (2001) commented:
It is of considerable concern that such disparities of practice exist among Canadian provinces and territories. There is an increasing body of evidence that the duration of untreated psychosis is correlated with a poor prognosis and that early intervention may prevent progression of the underlying disease process. Moreover, it is also clear that psychosis occurring at a young age can interfere with the completion of such important developmental tasks as schooling, vocational training, and psychosocial treatment. (…) [t]here is evidence (…) that higher rates of homelessness, violence, victimization, and criminalization occur when individuals with a mental illness are not treated than when they are treated. Conditional leave and community treatment order measures are now common in Canadian jurisdictions and are becoming widespread in other countries. They have been shown to effectively reduce hospitalization and to facilitate treatment adherence.
Should more uniformity among the various provincial and territorial mental health legislation be encouraged? Do disparities in mental health law reflect diverging views on the balance between protection of vulnerable persons, individual rights and freedom, and public safety? Gray, Shone and Liddle (2000) eloquently pointed out that, ultimately, mental health legislation is a matter of societal values:
Society must ask itself whether, in the name of freedom, people with a treatable brain illness who are escaping delusional enemies should be left suffering and homeless because they are not physically dangerous. Does society value the “right to be psychotic” to the degree that it should allow people to refuse treatment and, therefore, stay detained and warehoused at great public expense for long periods of time, putting themselves and others at risk of serious harm? Or should society keep people in hospitals when, with appropriate legislation, they could be at home in the community? Does society prefer to have people functioning in the community because they are legally required to take treatment or does it want these people to have repeated psychotic episodes and involuntary hospitalizations? A compassionate and just society must weigh these options including concerns for minimizing state intrusion in people’s lives.
All provinces and territories have undertaken the reform and renewal of their mental health care and addiction treatment system. Some jurisdictions are more advanced than others, but all share similar goal and principles. Similarly, most provinces face similar challenges and barriers to improving the provision of mental health services and supports and addiction treatment.
The Committee concurs with witnesses that the “silo philosophy” of policy planning and delivery of mental health services/supports and addiction must be addressed, through better integration, partnerships and collaboration. This is a critical step towards the development of a truly effective and genuine mental health and addiction system.
We also agree with witnesses that individuals with mental illness and addiction and non-governmental organizations must participate in the reform of the system. The development of a seamless system will only occur with the benefit of their first-hand experience and knowledge.
Achieving a truly seamless system of mental health services/supports and addiction treatment that is oriented to individuals with mental illness and addiction also requires tackling numerous challenges related to human resource planning and primary health care reform. In addition, more emphasis must be placed on early detection and intervention. In particular, the unique needs of children and adolescents must be addressed in a timely fashion.
The Committee also agrees that individuals living with severe mental disorders are particularly vulnerable and that, accordingly, the provision of mental health services and addiction treatment must reflect an appropriate balance between the rights of these individuals and the role of society in caring compassionately for them. It is important to decide whether the current disparities found in mental health legislation across the provinces and territories require formal review.
Given the level of burden of mental health issues and mental illness on society, Canadian governments can no longer afford to ignore reality. The time has come to redress historical imbalances.
Canada can only achieve the holistic vision of mental health (…) if it addresses complex interrelated issues in a coordinated fashion. What is needed now is collaborative national leadership in a national action strategy. We hope that the federal government will embrace this challenge. As citizens, we all serve to benefit.
[Canadian Mental Health Association, Brief to the Committee, June 2003, p. 29.]
This chapter examines the role and responsibility of the federal government in developing policies and programs in the field of mental health, mental illness and addiction. It also outlines various federal initiatives relevant to the development of an overall framework for mental health, mental illness, and addiction. In doing so, it attempts to separate the initiatives of the federal government for populations directly under its jurisdiction from others with a broader national focus involving multi-jurisdictional issues, notably those of primary concern to Canada’s provinces and territories.
Section 9.1 provides an overview of the direct and indirect roles of the federal government in mental health, mental illness and addiction. Section 9.2 describes and assesses the direct role of the federal government with respect to the specific population groups that fall under its responsibility, including First Nations and Inuit; federal offenders; veterans and the Canadian Forces; Royal Canadian Mounted Police; and federal public servants. Section 9.3 examines federal interdepartmental coordination relevant to its direct role in mental health, mental illness and addiction. Section 9.4 reviews the roles and responsibilities of the federal government from a national perspective (indirect role); it also examines the legal and financial levers available to influence policy in the field of mental health, mental illness and addiction. Section 9.5 provides a general assessment of some federal policies and programs affecting the delivery of mental health services, addiction treatment and social supports. Section 9.6 discusses the potential for a national action plan. Section 9.7 examines mental health, mental illness and addiction from a population health perspective. Section 9.8 contains the Committee’s commentary.
To provide a “picture” of the extent of the federal government’s role in mental health, mental illness and addiction, the Committee’s researchers searched the federal consolidated statutes and regulations using the terms “addiction”, “disability”, “mental disorder”, “mental health”, “mental illness”, and “substance abuse”. Table 8.1 provides the list of federal legislation that makes reference to these terms.
It appears clearly that the federal government has a role on two fronts in mental health, mental illness and addiction. On one front, it is directly responsible for specific groups of Canadians. According to the 2003 Canada’s Performance Report to Parliament: “The federal government provides primary and supplementary health care services to approximately 1 million eligible people – making it the fifth largest provider of health services to Canadians. These groups include veterans, military personnel, inmates of federal penitentiaries, certain landed immigrants and refugee claimants, serving members of the Canadian Forces and the Royal Canadian Mounted Police, as well as First Nations populations living on reserves and the Inuit.” In addition, the federal government is a major employer with management of a large workforce with particular health-related concerns.
On the second front, the federal government is expected to bring a national perspective to the social policy field that includes mental health, mental illness and addiction. This is an indirect role incorporating broad responsibility to oversee the national interest of all Canadians. It discharges this responsibility in several ways, including funding transfers to the provinces, surveillance activities and data collection, funding and performance of research and development activities, drug approval process, the provision of income support and disability pension provisions for affected Canadians, social programming such as housing initiatives, funding the criminal justice system, and the operation of a number of programs to promote overall population health and well-being.
FEDERAL LEGISLATION WITH RELEVANCE TO
MENTAL HEALTH, MENTAL ILLLNESS AND ADDICTION
Canada Elections Act
Canada Pension Plan
Canada Student Financial Assistance Act
Canada Student Loans Act
Canadian Centre for Occupational Health and Safety Act
Canadian Centre on Substance Abuse Act
Canadian Forces Superannuation Act
Canada Health Act
Canadian Human Rights Act
Canadian Institutes of Health Research Act
Controlled Drugs and Substances Act
Corrections and Conditional Release Act
Department of Health Act
Excise Tax Act
Federal-Provincial Fiscal Arrangements Act
Food and Drugs Act
Income Tax Act
Members of Parliament Retiring Allowances Act
Parliament of Canada Act
Pension Benefits Standards Act
Personal Information Protection and Electronic Documents Act
Public Service Employment Act
Public Service Superannuation Act
Royal Canadian Mounted Police Superannuation Act
Supplementary Retirement Benefits Act
Vocational Rehabilitation of Disabled Persons Act
War Veterans Allowance Act
Youth Criminal Justice Act
Source: Law and Government Division, Library of Parliament.
In both roles, any consideration of a framework for mental health, mental illness and addiction cannot displace the primary responsibility of the provinces/territories for program design and delivery. There is, however, an overriding need to move toward a framework that works for all Canadians regardless of whether they fall under federal or provincial jurisdiction.
The distinction between the federal and the provincial/territorial responsibilities with respect to mental health addiction services has been clearly emphasized by Tom Lips, Senior Advisor, Mental Health, Healthy Communities Division, Population and Public Branch, Health Canada, when he stated:
The federal and provincial-territorial roles and responsibilities differ where mental health and mental illness are concerned. (…) Provincial and territorial governments have primary responsibility for the planning and delivery of health services for the general population. As you know, federal transfer payments contribute to health services delivery. The federal government has a special mandate for health service delivery to certain populations, notably First Nations people on reserve and Inuit. It also undertakes national health promotion efforts. Both levels of government have been involved in health promotion, research and surveillance, and have collaborated to address some service delivery issues, for example, identifying best practices.
In fact, the range of federal programs and services relevant to mental health, mental illness and addiction is very large. It includes multiple initiatives aimed at specific groups under its direct responsibility and many endeavours to address broader national population concerns. The following sections examine the more specific federal and the broader national perspectives and, where possible, provide some information to assess those program and service activities.
Aboriginal peoples are defined in the Constitution Act, 1982 (section 35) as the “Indian, Inuit and Métis peoples of Canada.” Despite this broad constitutional definition, the federal government currently takes responsibility only for Indian people residing on-reserve and specified Inuit. Health Canada estimates that it serves approximately 735,000 eligible First Nations and Inuit people.
The provincial and territorial governments have general responsibility for Aboriginal peoples living off-reserve, including Métis and non-status Indian populations. These groups have access to programs and services on the same basis as other provincial residents. These jurisdictional divisions, in combination with the multifaceted nature of the Aboriginal population in Canada, have created serious barriers to the establishment of a comprehensive plan for the development of a genuine system of mental health, mental illness and addiction.
Over the years, the federal government has made several attempts to address mental illness and addiction in Aboriginal communities. In the early 1990s, the federal department of health, with the assistance of a multi-stakeholder steering committee, produced an “Agenda for First Nations and Inuit Mental Health.” It also targeted Aboriginal peoples in broader strategies such as the Drug Strategy, Family Violence Prevention Initiative, and Building Health Communities Initiative. In 1996, the Royal Commission on Aboriginal Peoples drew particular attention to the mental health problems that were linked to poverty, ill health and social disorganization in many communities.
The federal government’s response to the Royal Commission, Gathering Strength – Canada’s Aboriginal Action Plan, was announced in January 1998; it provided a strategy to begin a process of reconciliation and renewal of its relationship with Aboriginal peoples. Two significant initiatives had as their goal to give Aboriginal peoples more autonomy when addressing some of the concerns related to health and mental health. First, in 1998, the federal government funded the Aboriginal Healing Foundation, an Aboriginal-run, non-profit corporation to support community-based healing initiatives of Métis, Inuit and First Nations people on and off reserve directed to those who were affected by physical and sexual abuse in residential schools and to those affected indirectly by intergenerational impacts. Second, in 1999, Health Canada collaborated with several Aboriginal organizations to establish the National Aboriginal Health Organization. Officially incorporated as the “Organization for the Advancement of Aboriginal Peoples’ Health”, this new organization focuses on priority areas of health information and research, traditional health and healing, health policy, capacity building and public education.
In 2003, $1.3 billion over five years was committed to develop an effective and sustainable health care system for First Nations and the Inuit. In the Throne Speech of February 2004, the federal government made further commitments aimed at ensuring a more coherent approach to multiple issues affecting Aboriginal communities. It promised to set up an independent Centre for First Nations Government, renew the Aboriginal Human Resources Development Strategy, expand the Urban Aboriginal Strategy, and establish a Cabinet Committee on Aboriginal Affairs.
At present, Health Canada and Indian and Northern Affairs Canada are the two major federal departments that provide health care, mental health services, addiction treatment and social services to First Nations and the Inuit.
Health Canada, through its First Nations and Inuit Health Branch, is responsible for the following programs that address mental illness and addiction:
· National Native Alcohol and Drug Abuse Program (NNADAP): This program is largely controlled by First Nations communities and organizations; it incorporates a network of 48 treatment centres and community-based prevention programs.
· National Youth Solvent Abuse Program: This program delivers, through 10 treatment centres, assessment, inpatient treatment and counseling intended for First Nations and Inuit adolescents with solvent abuse problems.
· Indian Residential Schools Mental Health Support Program: This program provides mental health and emotional support to eligible individuals who are resolving claims against the Government of Canada for abuse(s) suffered while attending Indian Residential Schools. It is provided by Health Canada in collaboration with Indian and Northern Affairs Canada.
· First Nations and Inuit Fetal Alcohol Syndrome/Fetal Alcohol Effects (FAS/FAE) Initiative: This purpose of this initiative, which is part of the Canada Prenatal Nutrition Program, is to raise awareness about FAS/FAE and to deliver programs that provide mental health services to persons at risk and detoxification services for pregnant women at risk, their partners, and their families.
· Non-Insured Health Benefits (NIHB) Program: NIHB provides eligible registered Indians and recognized Inuit and Innu with medically necessary health-related goods and services that are not covered by other federal, provincial, territorial or third-party health insurance plans. These benefits complement provincial/territorial insured health services and include drugs, medical transportation, dental care, vision care, medical supplies and equipment, crisis intervention and mental health counseling.
· Aboriginal Head Start on Reserve: This initiative is designed to prepare young First Nations children for their school years, by meeting their emotional, social, health, nutritional and psychological needs. This initiative collaborates with Health Canada's Brighter Futures and Building Healthy Communities programs. Additional collaboration involves Human Resources Development Canada's Child Care Initiative and the Department of Indian and Northern Affairs' Kindergarten program, both at national and local levels, to ensure that Aboriginal Head Start on Reserve fills gaps and complements existing programs.
At Indian and Northern Affairs Canada, social policy and programs include Child and Family Services, Social Assistance, Adult Care, the National Child Benefit program and other social services that address individual and family well-being. All have components relevant to mental health. Specific programs addressing mental illness and addiction include:
· Aboriginal Suicide Prevention Program: This program, which is provided in collaboration with the RCMP, teaches young adults and community caregivers how they can help prevent suicides. Participants are selected by elders and other Aboriginal community leaders.
· Aboriginal Shield Program: This program is provided in collaboration with the RCMP; it offers education on substance abuse to Aboriginal communities. The program assists Aboriginal and non-Aboriginal police officers as well as community leaders, health care workers, teachers and youth leaders.
· Family Violence Prevention Program: The program provides operational funding to shelters located in First Nations communities. It also funds community-based family violence prevention programs that aim to prevent incidents of family violence on reserves.
Witnesses told the Committee that federal programs addressing mental illness and addiction in First Nations and Inuit communities do not adequately address the needs of Aboriginal peoples. For example, Dr. Cornelia Wieman, Psychiatrist from the Six Nations Mental Health Services (Ohsweken, Ontario), talked about the psychiatric counseling sessions available under Health Canada’s Non-Insured Health Benefits Program:
[Under NIHB], the limit is 15 sessions with the possibility of renewing for a further
12. A total of 27 sessions for many people is not sufficient to help them adequately address their mental health concerns. The mandate of the NIHB program is to provide support for clients in crisis or who cannot access counseling by other means. That counseling could be from an outpatient psychiatric clinic or health service that is funded by the provincial health care system. They could also pay for private counselling.
The vast majority of my patients live on a limited income and would not be able to pay for private counseling. As a result of transportation and access issues, many are also not able to access counseling services in smaller communities nearby or in larger urban settings such as
Hamilton. You can tell that these people do fall through the cracks in the system.
Perhaps more importantly, witnesses identified the existing First Nations and Inuit program “silos” as a significant barrier to accessing needed mental health services and addiction treatment. Services and supports are provided without much collaboration by different departments, or by various departmental directorates or divisions. Moreover, the Committee was told that the current practice is to isolate problems on the basis of their symptoms – addiction, suicide, FAS/FAE, poor housing, lack of employment, etc. – and to design stand-alone programs to manage each one. This fragmented approach has had little success. Witnesses told the Committee that, in order to restore the well-being in First Nations and Inuit communities across the country, a significant re-thinking of, and departure from, current practice is needed.
The Committee was also informed that the fragmentation of services set up to solve interconnected issues is a real problem. In particular, we heard that First Nations and Inuit are poorly served by government program delivery models that stress services to individuals over holistic, more culturally-appropriate, services to communities. For example, Dr. Laurence Kirmayer, Director, Division of Social and Transcultural Psychiatry, Department of Psychiatry, McGill University, stated:
Mental health perspectives tend to be focused on the individual and on individual vulnerability and affliction. This kind of data really points to the working of social forces – things that are affecting entire generations of people and we need to conceptualize it in that way. Within this pattern there is individual vulnerability; not everyone is affected the same way by the same adversity. However, the overall high rate suggests that many people are being affected and that there are things that lie outside of the individual that are at play. We have the challenge to characterize social forces and to think about ways of helping people to take that in hand.
Witnesses also stressed that the “one size fits all” approach to program and service delivery has not met the needs of Aboriginal peoples effectively. By and large, Aboriginal peoples know what their problems are, and are in better position to identify appropriate solutions, and to know what resources should be applied in accordance with community priorities. What this means, in structural terms, is that it would be far preferable for government departments to delegate to Aboriginal communities the authority to customize services and react flexibly to local circumstances. Accordingly, Aboriginal peoples should be supported in their development of their own solutions, rather than having solutions imposed upon them from “outside”.
To be successful, community-based initiatives must be accompanied by the development, in parallel, of community capacity adequate to deliver such programs effectively. Witnesses identified a critical shortage – if not absence – of adequately trained mental health and addiction professionals. In this perspective, Dr. Wieman stated:
One of the important ways in which access to health services and health outcomes, including mental health, can be improved is by training an increased number of Aboriginal health professionals. Barriers to seeking various mental health services could be overcome and providing more culturally relevant care could be accomplished. The Royal Commission on Aboriginal Peoples in 1996 recommended that 10,000 Aboriginal peoples be trained as health professionals in the next 10 years. We are now only two years away from 2006, and I do not believe that we are anywhere near that goal. Estimates state that there are approximately 150 Aboriginal physicians in this country, most of whom have trained to be family physicians. Off the top of my head, I would estimate the number of Aboriginal specialists at probably less than 25. I am only aware of two other Aboriginal psychiatrists in this country, with a fourth individual graduating from the residency program in
Manitoba this June.
The Committee was also informed that the needs of Aboriginal peoples are complex and that short term approaches often fail. More precisely, short term funding can materially restrict the ability of Aboriginal governments to develop the long term strategies needed to address the needs of their communities. It can take years to develop effective programs, and often, the shorter the time frame of a given project, the less potential there is for it to be effective.
There was also a general consensus among witnesses that the current funding levels for mental health services and addiction treatment in First nations and Inuit communities are inadequate. Brenda Restoule, Psychologist and Ontario Board Representative, Native Mental Health Association of Canada, explained:
Current funding is already inadequate, at best, and does not meet the needs of the community and its members. Since the funding formula is based on population size, many communities receive a small amount of funding, making it difficult or, in many cases, impossible, to deliver mental health counselling and intervention services. Most communities must use their funding to establish mental health promotion and mental illness prevention programs. Although these types of programs are needed, the funding does not allow for a continuum of care that is desperately needed for First Nation communities.
The funding is so low for the salary of mental health workers that professionals such as social workers, psychologists and psychiatrists often do not find it desirable to work in First Nation communities.
The Committee was informed that some provinces have integrated Aboriginal issues within their mental health strategies. To be truly successful, then, federal initiatives for Aboriginal mental health either on reserve or off-reserve should harmonize with the relevant provincial mental health plans and implementation strategies.
To sum up, federal and provincial programs directed to Aboriginal mental health, which focus on individuals or specific aspect of an issue, have been criticized for operating with a silo mentality that precludes their smooth coordination with other programs. The result is an hodge-podge of similar programs, different tiers of service delivery and a complex array of funding mechanisms that is bewildering to the individuals they are intended to serve and their families and communities. Ideally, a holistic or global approach would entail government departments pooling their resources so that interconnecting factors such as health, education, housing, and employment needs of individuals, families and communities could all be met or at least alleviated in a planned, structured and integrated way. Horizontal government initiatives would assist Aboriginal communities to plan and coordinate services better.
From a financial perspective, the lack of coordination often results in expensive and unnecessary program duplication. An environmental scan is required to determine what programs exist, where there is duplication across departments and organizations, where there are significant gaps in programming, as well as how best to maximize resources.
Inmates in federal correctional institutions and others under the federal correctional system, those offenders who are sentenced to two years or more of incarceration, constitute another significant group of Canadians under federal health-related responsibility. Currently, Correctional Service Canada (CSC) manages about 12,600 inmates and 8,500 offenders on conditional release under parole officer supervision. The quality of mental health services and addiction treatment for federal offenders is a consideration for CSC but it is secondary to the primary focus of corrections, which is described as the “criminogenic” needs.
Federal offenders come completely under federal responsibility and are not considered as beneficiaries of provincial health care insurance plans. Françoise Bouchard, Director General, Health Services at CSC, observed that the legislative health care mandate of federal corrections is through the Corrections and Conditional Release Act, which states:
The service shall provide every inmate with essential health care and reasonable access to non-essential mental health care that will contribute to the inmate’s rehabilitation and successful reintegration into the community.”
With respect to mental health care, the goal of CSC is to provide: “a continuum of essential care for those suffering from mental, emotional or behavioural disorders (…) consistent with professional and community standards.”
When admitted to the correctional system, each individual is assessed and asked fundamental questions about his/her mental health, mental illness and addiction. Following assessment, a correctional plan is developed for each offender and the offender is directed to either a regular institution or one in which treatment is available.
Over the last decade, CSC has issued specific directives on mental health services and addiction treatment provided to federal offenders. In 1994, directives from the Commissioner were implemented for psychological services, including assessment; therapeutic intervention; crisis intervention; program development, delivery and evaluation. In 2002, directives on mental health services provided standards on assessment, diagnosis and treatment that affect the access to mental health professionals, emergency and community care, as well as transfers to psychiatric care and addiction treatment centres. The same year, the CSC Commissioner issued directives for methadone maintenance treatment (diagnosis and treatment). In 2003, directives for the purpose of offenders who are suicidal or self-injurious were released; they include prevention, assessment and treatment guidelines. Also in 2003, a directive on health services was issued that stipulates that the cost of providing mental health and addiction treatment will be the responsibility of CSC.
In addition to these directives, CSC has worked to develop a comprehensive health care strategy to address both the physical and mental health needs of offenders, including the integration of issues related to drugs and alcohol. Specific work on mental health policy included a 1991 Task Force report on mental health oriented to all offenders, a 1997 National Strategy on Aboriginal Corrections, and a 2002 mental health strategy for women offenders.
At CSC, the Aboriginal Initiatives Branch is mandated to create partnerships and strategies that enhance the safe and timely reintegration of Aboriginal offenders into the community. Aboriginal peoples represent less than 3% of the Canadian population, but account for 18% of the federally incarcerated population. Aboriginal-specific and culturally appropriate programs and services to address the needs of Aboriginal offenders in corrections include initiatives such as Aboriginal Healing Lodges (9 across Canada); Aboriginal Community Residential Facilities (23 across Canada); Aboriginal Community Reintegration Program; Elders working in institutions and in the community; and Transfers of Correctional Services to Aboriginal Communities (5 agreements signed). CSC is also responsible for the “National Strategy on Aboriginal Corrections” (currently being revised) that focuses on Aboriginal programs, Aboriginal community developments, Aboriginal employment/recruitment and partnerships on Aboriginal issues.
Women with particular mental health needs at all security levels may receive treatment in a specialized, separate 12-bed women's unit at the Regional Psychiatric Centre in the Prairies (RPC). This unit serves also as a national mental health resource for Anglophone women. Francophone women may receive treatment at Institute Phillipe Pinel in Montréal (Québec) where CSC has contracted for inpatient treatment services. Furthermore, the “2002 Mental Health Strategy for Women Offenders” provides a framework for the development of mental health services covering a continuum of care. The goal is to apply the elements of the strategy to all offenders and to include crisis intervention, acute care programs, chronic care programs, special needs units, outpatient treatment, consultation services, discharge and transfer planning, follow-up as well as interconnection with other programs and services.
CSC also delivers the “Substance Abuse Program” which consists of a range of institutional and community-based programs that are matched to the severity of the offender’s substance abuse problem. The program is cognitive-behavioural in orientation and includes a strong emphasis on structured relapse prevention techniques. The program is also responsible for the provision of methadone maintenance treatment.
Officials from CSC told the Committee that mental health care and addiction treatment are required to: reduce the disabling effects of mental disorders in order to maximize each inmate’s ability to participate electively in correctional programs, including their preparation for community release; help keep the prison safe for staff, inmates, volunteers and visitors; and decrease the needless extremes of human suffering caused by mental disorders.
The Committee heard that access to mental health services and addiction treatment, however, requires an enhanced CSC response capacity. CSC has 5 specialized treatment centres spread across the country, but they are not resourced at levels comparable to that of provincial forensic facilities. Although CSC has many psychologists, these are primarily engaged in risk assessment for conditional release decision-making. In addition, there is no specific training for correctional staff on mental illness and addiction. With respect to the Mental Health Strategy for Women Offenders, the Committee was told that the challenge of this new approach is that women requiring mental health intervention must move to another part of the country to obtain needed services.
Witnesses also talked about the need for better links between the federal and provincial governments and between the justice system and the provincial mental health services system. For example, Ms. Bouchard from CSC stated:
There is a need for a comprehensive, inter-jurisdictional strategy for the identification and management of offenders with mental disorders. While we try to do a comprehensive assessment at reception, much still needs to be done in respect of those identifying offenders who have mental health problems early in their sentences. That should also occur within the provincial systems as early as possible.
There is a need to have better links between the justice system and the health care system within the provinces. The search for solutions should start before imprisonment for those afflicted with mental health disorders. Within the federal corrections system, work is under way to improve capacities to assess and treat. However, we have no guarantees we will ever have additional resources to do that. We are, right now, conducting a review of our utilization of beds in our treatment centres to maximize and direct them to those who have the most needs. Sometimes that calls for a change of culture between correctional culture and treatment culture, so there is lots of work still to be done.
Our last observation is the issue of continuity of care when people are released. This calls for better links between us, at the federal correctional level, and our provincial counterparts and the community mental health care out there. Partnerships are key to address those gaps, but what will be the incentive to create those partnerships?
The Committee also heard about some discriminatory aspects of the judicial system. For example, Patrick Storey, Chair of the Minister’s Advisory Board on Mental Health (British Columbia), stated:
For federal offenders, it is difficult to access provincially funded mental health services in the community due to specific provisions of the Mental Health Act of
British Columbia. This act is, in itself, discriminatory to this population. It directs that directors of provincial facilities not provide care to people from federal institutions. That is a federal government funding responsibility, and so people who are in federal prison with mental illness trying to get a release into the community will not get service from the local mental health centre or from other services, which is intolerable. (…) Federal and provincial correctional authorities and health authorities must work together to address these deficiencies and reduce the discrimination faced by people in conflict with the law.
In addition, the Committee was told that there is a need to harmonize better the Criminal Code with provincial mental health legislation. The Schizophrenia Society of Canada explained that under the Criminal Code a judge may order a person who is found not fit to stand trial to undertake treatment to make them fit. However, neither the judge nor the Board of Review can order treatment of a person found not criminally responsible based on mental illness to make them well enough to be discharged. The theory is that the provincial mental health acts will do that. In some provinces, however, that does not happen. The Schizophrenia Society of Canada recommended that the federal government should amend the Criminal Code to allow the Review Board to order treatment necessary for the probable release of a person affected by treatable mental illness. In their view, this is preferable to requiring the same person to stay incarcerated for an unreasonable time because the untreated illness makes him/her a significant threat to the safety of the public.
Ms. Bouchard from CSC made some observations about the need for better community supports:
Addressing the needs of offenders who require specialized mental health intervention can reduce the “revolving door”' phenomenon. There is what we call a revolving door between corrections, both federal and provincial, but also the community, where often people who are afflicted with mental health disorders find themselves in the criminal justice system. While mentally disordered offenders are often less likely to reoffend – including violently – they are more likely to return to prison due to a breach of their release conditions – often as a result of inadequate support while they are in the community.
Veterans Affairs Canada is responsible for delivering health services and pensions and for providing social and economic support to more than 150,000 aging Canadian veterans and members of the Canadian Forces (CF). The main beneficiaries are those veterans and civilians granted a pension or allowance.
The Canada Health Act specifically excludes CF members from the definition of “insured persons”. Therefore, CF members are not eligible for hospital care and physician services insured under provincial health care insurance plans. The Canadian Forces Health Services (CFHS) is the designated health care provider for 83,000 Regular and Reserve Forces personnel at home and on deployment. The CFHS provides access to more than 85,000 providers across the country. Atlantic Blue Cross Care has responsibility for program administration and payment.
Veterans Affairs Canada administers Ste. Anne’s Hospital, located in Ste-Anne-de-Bellevue, Québec. The hospital provides medical and paramedical services to its residing veterans, in addition to a wide range of recreational and social activities. Ste-Anne’s Centre, part of the hospital, provides mental health services to CF members and veterans; it has developed specialized expertise in the fields of post traumatic stress syndrome and dementia. Inpatient and outpatient care are also provided in contract hospital beds, in veterans’ homes, and in hospitals of choice.
Veterans Affairs Canada also provides pensions for disability or death and economic support in the form of allowances to various groups. These include: members of the Canadian Forces and Merchant Navy veterans who served in the First World War, the Second World War or the Korean War; certain civilians who are entitled to benefits because of their wartime service; former members of the Canadian Forces (including those who served in Special Duty Areas) and the Royal Canadian Mounted Police; as well as survivors and dependents of military and civilian personnel.
The Department of National Defence is responsible for “Strengthening the Forces”, a health promotion initiative designed to assist CF and Regular and Primary Reserve members to take control of their health and well-being. Suicide prevention and substance abuse interventions for tobacco and alcohol are two important components of this initiative. Mental health is an issue of concern within Strengthening the Forces. Beside its focus on active living, injury prevention and nutritional wellness, the initiative includes: “Addiction Free” (alcohol and other drug abuse, tobacco use cessation, problem gambling) and “Social Wellness” (stress management, anger management, family violence prevention, healthy families, suicide prevention, and spirituality).
Health Canada is responsible for occupational health and safety of CF members. The “Canadian Forces Member Assistance Program” is organized by the Workplace Health and Public Safety Program (WHPSP) at Health Canada; it is a 24/7 toll-free telephone service that provides confidential counseling services to help members and their families when they have personal concerns that affect their well-being or work performance.
Several reports have identified gaps in the care and treatment of CF personnel by the Department of National Defence specifically and, by extension, Veterans Affairs Canada. These included: the McLellan and Stow reports in April 1998, the Goss Gilroy Report in June 1998 and the October 1998 report from the House of Commons Standing Committee on National Defence and Veterans Affairs.
The departments responded with a series of initiatives relevant to mental health. In April 1999, the DND-VAC Centre for the Support of Injured and Retired Members and Their Families opened in Ottawa to provide information, referral and assistance support to former and current CF members and their families. Subsequently, legislative and regulatory reform made access to services and benefits more equitable to all CF members, regardless of whether the injury occurred in Canada or on foreign deployment. In April 2001, Veterans Affairs launched an Assistance Service for former members of the CF and their families who require professional counseling.
Recently, the major mental health focus for Veterans Affairs Canada and the Department of National Defence has been on the needs of CF members and veterans suffering from post-traumatic stress disorder and other operational stress injuries. In February 2004, they jointly announced a Canada Mental Health Strategy for the Canadian military. This strategy creates a network of mental health assessment and treatment facilities, educational forums, continuing education program and research for post-traumatic stress disorder and operational stress injuries.
The Royal Canadian Mounted Police (RCMP) is an agency of the Ministry of Public Safety and Emergency Preparedness Canada. In addition to federal policing services for all Canadians, it provides policing services under contract to the three territories, eight provinces (all except Ontario and Quebec), approximately 198 municipalities and, under 172 individual agreements, to 192 First Nations communities. The on-strength establishment of the Force as of January 1, 2004, was 22,239.
The definition of “insured persons” under the Canada Health Act excludes members of the RCMP. The administration of health care insurance for the RCMP has been the responsibility of Veterans Affairs Canada since 2003. Veterans Affairs Canada also assumes responsibility for the direct payment of disability pensions for approximately 3,800 RCMP pensioners as well as the provision of health care benefits for approximately 800 retired and civilian pensioners.
The federal government is a major employer. Although the size of its workforce diminished between March 1995 to March 2001 from 225,619 to 155,360 employees, it is reported to have grown in the last few years.
In its role as the general manager and employer of the federal public service, Treasury Board oversees benefits available to public servants such as the Public Service Health Care Plan that covers medical benefits and the Disability Insurance Plan that assures a reasonable level of income during periods of long-term physical or mental disability. It has mandated Health Canada to provide occupational health and safety services such as Employee Assistance Programs for Part I, Schedule I, Public Service employers.
The Public Service Health Care Plan (PSHCP) is a private health care insurance plan established for the benefit of federal public service employees, CF members, the RCMP, members of Parliament, federal judges, employees of a number of designated agencies and corporations, and persons receiving pension benefits based on service in one of these capacities. The PSHCP is funded through contributions from the Treasury Board of Canada, participating employers, and the Plan members. The administrator, Sun Life Assurance Company of Canada, is responsible for the consistent adjudication and payment of eligible claims.
PSHCP reimburses participants for all or part of costs they have incurred for eligible services and products, only after they have taken advantage of benefits provided by their provincial/territorial health care insurance plan or other third party sources of health care expense assistance. Eligible services and products are prescribed by a physician or a dentist who is licensed to practice in the jurisdiction in which the prescription is made. PSHCP reimburses eligible expenses on a “reasonable and customary” basis to ensure that the level of charges are within reason in the geographic area where the expense is incurred.
PSHCP covers the cost of visits to a psychologist up to a certain specified limit of maximum eligible expenses. A psychologist prescription covers up to one year of services. The current rate of payment from the plan is about 80 percent of $1,000 per calendar year, covering between 5 and 6 sessions per client.
Under the Long Term Disability Insurance Plan, benefits are payable for up to 24 months in respect of any medically determinable physical or mental impairment which a) results in the withdrawal of any mandatory licence required by the employee to carry out his or her occupation or employment, or b) renders the employee completely incapable of performing substantially all of the essential duties of his or her occupation or employment.
Short term counseling is offered through Employee Assistance Programs (EAP) that can assist people seeking help in juggling personal and work-related demands. A nationwide 24 hour toll-free (1-800) telephone line is operated by qualified and experienced bilingual counselors; access to counseling to over 600 qualified psychologists and social workers (or equivalent) is also provided. Referrals can also be made for employees with personal or work-related problems to resources within the Public Service or in the community, when appropriate, and follow-up is provided. Federal organizations that are clients of the Employee Assistance Society of North America include: Department of National Defence, Department of Veterans Affairs, Department of Justice, Office of the Auditor General of Canada, Health Canada, Parks Canada, Environment Canada, Citizenship and Immigration, Department of Indian Affairs and Northern Development, Fisheries and Oceans, and the Transport Safety Board.
The services described above do not replace those provided by the Public Service Health Program. Within the Healthy Environments and Consumer Safety Branch at Health Canada, the Workplace Health and Public Safety Program (WHPSP, formerly called the Occupational Health and Safety Agency) is mandated by Treasury Board to provide occupational health and safety services (including psychological services) for Part I, Schedule I, Public Service employers.
In addition, Critical Incident Stress Management Services (CISMS) are available for dealing with traumatic incidents such as the death or serious injury of a co-worker on the job, a mass casualty, a threat, personal assault or other forms of violence in the workplace. Employees in certain occupational groups known as “emergency service workers” ( e.g., law enforcement officers, firefighters, nurses and other health care workers, search and rescue teams) are at greater risk of experiencing traumatic incidents. Services include education/prevention, intervention, and evaluation.
Recent studies have explored the issue of stress and the need for the federal government as an employer to make a greater effort to ensure work/life balance and healthy living for its employees. In January 2003, the federally-sponsored National Study on Balancing Work, Family and Lifestyleconducted by Linda Duxbury and Christopher Higgins for Health Canada was released. It confirmed that employed Canadians wanted flexible work schedules, limits on overtime, opportunities for part-time work, telework and family care provisions to help them achieve a better sense of balance in their lives. The study included public (including 8 federal departments) as well as private sector employees and found that public servants take a significant number of “mental health” sick days and spend more on prescription drugs than private sector employees.
Another study conducted in 2002 by the Association of Professional Executives of the Public Service of Canada (APEX) found a significant increase in rates for coronary and cardiovascular diseases (CVD), particularly hypertension, among public employees. It also pointed to other key indicators of health status that demonstrated gradual deterioration. Among respondents, 95% reported sleep disturbances and an average of only 6.6 hours sleep per night; 15% reported depressed mood; 53% reported high levels of stress, almost twice the rate for the average Canadian of the same gender and age; and 19% reported musculo-skeletal problems related to tension. Overall, the data showed that as a group, public service executives experience stress in the high to extreme range.
Bill Wilkerson, co-founder of the Global Business and Economic Roundtable on Addiction and Mental Health stated that: “As an employer, the public sector needs to look deep within itself,” arguing that “we need governments as employers who lead by example in the promotion of mental health and prevention of mental disability.” Referring to the APEX study, he noted that “more than fifteen per cent of executives in the public service suffer depression – 50 per cent higher than the national average. (…) For senior civil servants, psychotropic medication is the prescription drug of necessity in 17.5 per cent of all drug utilization.”
Citizenship and Immigration Canada (CIC) has responsibility for the assessment of landed immigrants and refugees. In the past 10 years, Canada has welcomed yearly an average of some 220,000 immigrants and refugees. A landed immigrant is one who has been granted the right to live in Canada permanently by immigration authorities. Refugees who are accepted to Canada are also landed immigrants. Refugee claimants do not have landed immigrant status; they arrive in Canada requesting to be accepted as refugees.
Those claiming refugee status who are needy or living in a province with a three month eligibility waiting period for coverage under the provincial health care insurance plan can get emergency or essential health services through the Interim Federal Health Program at Citizenship and Immigration Canada (CIC). Landed immigrants arrange their own health care, including private insurance to cover the three month waiting period imposed in four provinces (British Columbia, Ontario, Quebec and New Brunswick). 
All applicants for permanent residence in Canada have a medical examination of their physical and mental condition. Based on this examination, applicants may be refused entry into Canada if they have a health condition that is likely to be a danger to public health or safety, or that could be very demanding on health or social services. Departmental information is not specific about possible responses to applicants with mental disorders of any severity.
With the knowledge that newcomers to Canada face tremendous challenges, Citizenship and Immigration Canada has several programs aimed at easing the stress of integrating into Canadian society. The department works with provincial/territorial governments and non-governmental organizations on several initiatives relevant to the positive mental health of immigrants. These include:
· Immigrant Settlement and Adaptation Program that funds organizations to provide services such as reception, orientation, interpretation, counselling and job search.
· Host Program that matches new arrivals with Canadian volunteers who offer friendship and introduce them to services in their community.
· Language Instruction for Newcomers to Canada Program that provides basic language instruction to adult immigrants to help them to integrate successfully.
For refugee claimants, the Interim Federal Health Program is available to cover some health care costs. Administered by Citizenship and Immigration Canada, it ensures emergency and essential health services for needy refugee protection claimants and those protected persons in Canada who are not yet covered by provincial health care insurance plans. The 2002-2003 Departmental Performance Report refers to additional funding of $7.6 million for the Interim Federal Health program, but does not indicate the program’s original cost. The Report for Plans and Priorities for 2003-2004 refers to the program as a “$50 million federal health insurance program covering emergency and essential health care for refugee claimants.” There is no breakdown of particular expenditures that might relate to mental illness or addiction. However, these could be significant, given that many refugee claimants have been victims of torture and other threats to their mental health.
In looking at federal government activities with respect to the specific groups under its responsibility, there is little evidence to suggest that there are specific population-targeted strategies, let alone a broad all-encompassing federal strategy applicable to all groups. Efforts are not apparent currently to develop an overall coordinated federal framework with collaboration by all involved departments or agencies. In most cases, there is little indication of a thorough and inclusive population specific strategy for addressing the mental health needs of any of the groups under federal responsibility. The provision of mental health services and addiction treatment and efforts toward mental health promotion and mental illness prevention remain highly fragmented, divided among numerous departments and departmental directorates.
There are, however, two examples of federal interdepartmental efforts to coordinate activities with respect to health care and substance abuse that may provide some lessons for future efforts to do the same in the specific field of mental illness and addiction. These are the Health Care Coordination Partnership and Canada’s Drug Strategy.
The Federal Health Care Partnership, formerly called the Health Care Coordination Initiative, was established in 1994 by a partnership of federal departments that were separately providing health care products and services to specific groups of Canadians. These departments believed that they could lower costs and improve delivery by working together. At present, Veterans Affairs has the lead role with other partners including the Department of National Defence, the RCMP, the Canadian International Development Agency, Correctional Services, Citizenship and Immigration, the Treasury Board Secretariat, Public Works and Government Services, and the Privy Council Office.
The key objectives of the initiative are to negotiate joint agreements with professional associations, suppliers and retailers; coordinate purchases of specific health care supplies and services; improve the competitive environment by identifying alternatives to traditional service delivery; improve information sharing and collective decision making; facilitate joint policy analysis and development; support cooperative development of health and information management across federal jurisdiction; and create joint health promotion activities.
In 2002-2003, the partners jointly negotiated fees, bulk purchases and collaborative policy development that collectively resulted in improved quality of service to clients and $11.6 million in cost savings. Savings of $17.6 million were forecast for 2003-2004. To date however, although there is great potential for joint action, no such activities have been in the field of mental health, mental illness and addiction.
The initial 1987 National Drug Strategy emerged from concern about the abuse of illegal drugs. In 1988, a national non-governmental organization, the Canadian Centre on Substance Abuse, was created by legislation to provide a focus for efforts to reduce the health, social and economic harm associated with substance abuse.
In 1992, Canada’s Drug Strategy was renewed and combined with the Driving While Impaired (DWI) Strategy. The continued objective was to reduce the harmful effects of substance abuse on individuals, families and communities by addressing both the supply of and demand for drugs. Coordinated by Health Canada (formerly the Department of National Health and Welfare), and involving several other departments, the Strategy sought to enhance existing programs and to fund new ones. Of the $210 million allocated to the initiative, 70% was directed to reducing the demand for drugs through prevention, treatment and rehabilitation and 30% to enforcement and control.
In 1998, the federal government reaffirmed its commitment to the principles of Canada’s Drug Strategy. Health Canada continued in its lead role and provided the chair for the Assistant Deputy Ministers’ Steering Committee on Substance Abuse and interdepartmental committees such as the Interdepartmental Working Group on Substance Abuse. The federal departments involved in the Strategy extended beyond those with direct responsibility for the health of Canadians; they included others with broader national and international relevance: Solicitor General, Foreign Affairs and International Trade, Finance, Canadian Heritage, Justice, Canada Customs and Revenue, Transport, Human Resources Development, Status of Women, Indian and Northern Affairs, Canada Mortgage and Housing Corporation, Treasury Board, and the Privy Council Office.
In its 2001 report, the Office of the Auditor General criticized Canada’s Drug Strategy for its fragmented approach and called for changes to the organizational culture throughout the federal government to emphasize structures and processes to maximize the benefits of working horizontally. When the comprehensive Drug Strategy for Canada was renewed in May 2003, the federal government committed $245 million and the support of fourteen collaborating federal departments. There will be a report to Parliament on the Strategy’s direction and progress in two years.
In addition to its direct federal responsibility, the federal government has a major indirect role in developing a national, long term, cross-jurisdictional, integrated, mental health plan. Although some witnesses claimed that mental health has never been a priority for any level of government, they also stressed their belief that mental health, mental illness and addiction are concerns affecting the entire population of Canada. Therefore, the federal government, the ten provincial governments and the three territories have interconnected roles to play in meeting the health and health care needs of Canadians affected by mental illness and addiction.
There is, however, no centralized departmental capacity, either within Health Canada or any other federal department, or through some form of national structure, to coordinate or respond from a national perspective to the full gamut of mental health, mental illness and addiction issues. Moreover, few resources are devoted to the intergovernmental aspects of a national framework in this area. Currently, work through various federal, provincial and territorial forums is limited to exploring options in shared care initiatives in primary health care reform, homecare proposals, and telehealth. The federal government is sensitive to the need to approach all such issues in a way that respects the federal/provincial/territorial division of responsibilities and the primary responsibility of the provincial and territorial goverments for the provision of mental health services and addiction treatment.
A formal structure – the Federal/Provincial/Territorial Advisory Network on Mental Health – was established on 17 April 1986 to advise the Conference of Deputy Ministers of Health on ways and means of ensuring federal, provincial and territorial cooperation on mental health issues. It was mandated to:
· Consider issues delegated by the Conference of Deputy Ministers of Health, or accepted by a significant number of the provinces as matters where a general consensus of informed opinion would be helpful, and make recommendations, where appropriate;
· Advise on the development and implementation of policies and programs for mental health services, with the aim of developing a uniformly high level of quality and effectiveness across Canada;
· Provide a forum to assist the provinces and territories in the development, organization and evaluation of mental health services within each jurisdiction;
· Serve as a forum for the presentation and exchange of information, relevant data, current research findings and expert opinion between the federal and provincial governments, universities and treatment settings, on problems of jurisdiction, organization, legislation, service delivery, evaluation and other relevant issues;
· Make proposals for federal, federal-provincial and provincial strategies for mental health promotion, to enhance the mental health status of the population at large and particularly that of children and adolescents;
· Receive reports on current mental health activities and programs at the national level and give advice, direction and support to these, as may be appropriate.
The work of the F/P/T Advisory Network on Mental Health was at the time supported by the Mental Health Division of Health and Welfare Canada. This division was then part of the department’s Health Services and Promotion Branch. In the late 1990s, however, the Council of Deputy Ministers of Health withdrew its support for the F/P/T Advisory Network. As a result, it is now difficult to find funding even to bring together mental health policy makers from across the country so that they can share information and develop coherent policies and plans. A number of provinces still continue to participate in the F/P/T Advisory Network, but their work is limited by the funding they can provide themselves. According to Dr. James Millar, Executive Director, Mental Health and Physician Services, Nova Scotia Department of Health, the dismantling of the F/P/T Advisory Network on Mental Health:
(…) has cut off a major venue for sharing and joint planning. Some jurisdictions continue to get together but struggle with funding. The number of meetings and jurisdictions participating has dropped off over the years. Special projects are funded on a formula basis with
Ontario covering the majority of the costs with Health
Quebec does not participate.
What then could the federal government do to encourage national coordination, collaboration and partnerships in the field of mental health, mental illness and addiction? There are two different types of levers available – legal (or policy) and financial (or fiscal) – for potential use in the mental health, mental illness and addiction area. While the federal government has legal authority through the power of criminal law, it has used its fiscal capacity to influence social policy. Neither lever, however, is well suited to achieve greater uniformity, establish and maintain standards, bring harmonization or establish national initiatives; these require a high degree of intergovernmental contact and willing collaboration.
The federal government has several legal avenues for application in mental health, mental illness, and/or addiction. Over the years, criminal law, the Charter of Rights and Freedoms and human rights have been applied.
The Criminal Code has particular sections that relate to mental disorders. For example, a person can be found not criminally responsible for an offence on account of mental disorder. The Court can order the initial part of a custodial sentence to be served in a treatment facility, when an offender is found to be “suffering from a mental disorder in an acute phase” and is in need of immediate treatment.
With respect to addiction, Parliament has used the power of criminal law in several instances. This authority was used to pass laws regulating the sale, distribution and possession of psychoactive substances through the Controlled Drugs and Substances Act. The Tobacco Act provides for a broad range of restrictions on the composition of tobacco products, the access of young persons to tobacco products, tobacco product labelling, and tobacco product advertisement endorsement and sponsorship. For alcohol, the Criminal Code covers driving while impaired and the Broadcasting Act and the Code for the Broadcast Advertising of Alcoholic Beverages regulates advertising.
As discussed in the previous chapter, the Canadian Charter of Rights and Freedoms guarantees certain legal rights that have application in mental health and addiction. Relevant sections deal with such matters as the right to life, liberty and security and the right not to be subject to cruel and unusual punishment. The Charter also has emerged as a mechanism for the creation of national standards which Canadians can demand that both federal and provincial governments meet.
The Canadian Human Rights Act of 1977 provides a process for resolving cases of discrimination in areas of federal jurisdiction. Discriminatory actions and attitudes are discouraged by means of persuasion and education and by ensuring that those who have discriminated will bear the costs of compensating their victims. The Act applies to all federal government departments, agencies and Crown corporations, as well as federally regulated businesses and industries (e.g., banking, transportation and communications).
Generally speaking, however, the federal government’s involvement is essentially fiscal in nature. As long as it does not legislate directly in relation to matters within the provincial/territorial jurisdictions, the federal government has used its taxing and spending power to launch a number of social program initiatives that are national in scope. Restraints on transfer payments to the provinces in the 1990s, however, prompted many provinces to demand that federal actions taken unilaterally with respect to transfers be replaced with processes involving greater provincial and territorial participation.
The federal spending power forms the basis for the Canada Health Act as well as for the current Canada Health Transfer and the Canada Social Transfer. It is the impetus for federal participation/incursion in other social policy areas such as housing and income security. The Canada Pension Plan (CPP), established by legislation in 1965, is another area where federal/provincial involvement. There are other such examples of social policy initiatives, income security for the disabled being one, that can enhance the mental health of all Canadians and, in particular, the quality of life of individuals with mental illness and addiction.
The area of mental illness, however, provides one example where the federal government’s constitutional spending power was applied and then withdrawn over the last 55 years. From the National Health Grants of 1948 to the First Ministers’ Accord on Health Care Renewal of 2003, federal funding arrangements have significantly affected mental illness and addiction either implicitly or explicitly.
Ambivalence over the place of mental health services in a national health care system was evident for many years the years. The 1948 National Health Grants Program, described as “the first stage in the development of a comprehensive health care insurance plan for all Canada,” encouraged “expansion of health services”including those for mental illness. One component of the program – the Mental Health Grant – was used to implement or expand mental health services, to strengthen professional and technical training facilities and to improve the quality and quantity of staff. In 1960-1961, the last year of the grant, some 53% of the funds were allocated to institutions, while 23% went to clinics and psychiatric units, 13% to training and 8% to research.
In 1957, however, the federal government’s Hospital Insurance and Diagnostic Services Act explicitly excluded psychiatric hospitals, although it did cover psychiatric services in general hospitals. This exclusion was based, at the time, by the view that mental hospitals provided custodial care and, as such, together with tuberculosis hospitals, nursing homes and other long term care institutions, they were not eligible for federal cost-sharing. In 1966, however, with the enactment of the Medical Care Act, public coverage was provided for physician services, including those provided by psychiatrists, regardless of setting.
The Federal-Provincial Fiscal Arrangements and Established Programs Financing Act, 1977 gave each province “block-funding”, a federal transfer payment based on its population and paid partly in cash and partly in tax points. This Act, under its definition of “extended health care services”, listed mental hospitals together with nursing home intermediate care service; adult residential care service; home care service; and ambulatory health care service.
In 1984, the Canada Health Act was enacted “to protect, promote and restore the physical and mental well-being of residents of Canada and to facilitate reasonable access to health services without financial or other barriers.” Most provisions of the two previous insurance Acts were consolidated in the new law; but one major change related to the new definition of extended care services: all references to mental hospitals was deleted.
In the 1990s, the role of the federal government in health care nationally and by extension its role in mental health was further curtailed as its transfer payments to the provinces and territories were reduced. In 1996, the Canada Health and Social Transfer (CHST) was established, merging the Established Programs Financing (EPF) and the Canada Assistance Plan (CAP); this left the provinces to decide themselves how to allocate their block funding among health care, post-secondary education and social programs.
When departmental legislation established Health Canada in 1996, it provided general guidance for the health minister concerning national health issues. More precisely, the Department of Health Act assigned responsibility to the Minister of Health to oversee “the promotion and preservation of the physical, mental and social well-being of the people of Canada.” This was interpreted as limiting the Minister to broad programs that promote and preserve mental and social well-being; monitoring mental health conditions or programs; conducting research and/or investigating mental health among other public health issues; and collecting and publishing statistics on mental health.
A turning point occurred in 1999 with the Social Union Framework and the related Health Accord that committed the federal government to increase funding for health care through the CHST, to ensure predictability of funding and to work collaboratively with all provincial and territorial governments to identify Canada-wide priorities and objectives. By 2000, the First Minister’s Communiqué on Health contained a pledge to “promote those public services, programs and policies which extend beyond care and treatment and which make a critical contribution to the health and wellness of Canadians.” In the 2003 Health Accord, the First Ministers agreed to provide first dollar coverage for a core set of fully portable home care services for community mental health services with access to them based on need. The plan is to have a range of services available including case management, professional services and prescribed drugs by 2006.
In addition to assistance with health-related services, the federal government has provided access to other programs to assist individuals with mental disability. For example, in 1961, the federal government agreed to share the cost of the Vocational Rehabilitation of Disabled Persons Program for mentally disabled persons of working age. In 1965, the Canada Pension Plan (CPP) offered disability benefits for a person with severe or prolonged mental disability. In 1966, the Canada Assistance Plan (CAP) offered the provinces 50% of the cost of shareable assistance and welfare services to people with disabilities, including mental disability. Cost sharing under CAP was considered instrumental in establishing community based social services integral to the provision of effective mental health supports in the community.
At present, through its Office for Disability Issues, Social Development Canada is the focal point within the federal government for work on the participation of Canadians with disabilities in learning, work and community life. Its key objectives include fostering policy and program coherence; building the capacity of the voluntary sector; creating cohesive, action-oriented networks and providing knowledge and building awareness. Other players include Canada Revenue Agency. Under the Income Tax Act, an individual with a severe and prolonged mental or physical impairment, or a person caring for a person with such impairment, can claim a disability tax credit.
Homelessness is another area in which the federal government used its spending power to facilitate development of a national framework. More precisely, the federal government launched in 1999 the National Homelessness Initiative (NHI), a community-based approach designed to alleviate and prevent homelessness. The initiative involves partnerships with all levels of government, the private sector and the voluntary sector. Its multidisciplinary approach reflects the belief that homelessness has no single cause and that the problem requires interventions in a number of areas, including the provision of shelter, opportunities for employment, mental health care, programs to combat drug abuse and welfare services. It recognizes the diversity of the needs of the homeless and the requirement for “tailored” responses and solutions relevant to specific communities.
While the federal government provides provinces and territories with funding in support of mental health services, social programs, income support and housing, the levels of funding for mental health services, per diem payments for transitional and supportive housing providers, and income assistance for individuals are all within provincial, territorial and municipal jurisdictions.
9.5 ASSESSMENT OF THE
FEDERAL ROLE WITHIN THE CURRENT NATIONAL FRAMEWORK
(…) when the Canada Health Act
was developed, mental health services provided in psychiatric hospitals
were excluded. The Act provides that only medically mental health
services provided in general hospitals and physician services will be
covered by the Act. This significant omission has left those trying to
provide mental health services at a serious disadvantage when providing
community based services.
[Dr. James Millar, Executive
Director, Mental Health and Physician Services, Nova Scotia Department
of Health (Brief to the Committee, 28 April 2004, p. 5.]
As mentioned above and previously,
the Canada Health Act expressly excludes from its definition of
comprehensiveness services provided in psychiatric institutions. Numerous
witnesses stated that this omission reinforces an artificial distinction
between physical and mental illness and contributes to the stigma and
discrimination associated with mental disorders. For example, Dr. Sunil V.
Patel, CMA President stated:
(…) it is (…) important to recognize the deleterious effect of the
exclusion of a “hospital or institution primarily for the mentally
disordered” from the application of the Canada Health Act. Simply put,
how are we to overcome stigma and discrimination if we validate these
sentiments in our federal legislation
Dr. Patel recommended that the Canada Health Act be amended to include psychiatric hospitals and that federal funding under the Canada Health Transfer be adjusted to provide for these additional insured services.
The Committee also heard that the exclusion of psychiatric hospitals from the Canada Health Act generates problems with respect to the principle of portability. More precisely, because psychiatric hospitals are explicitly excluded from the Act, they are not subject to reciprocal billing arrangements between provinces. Ray Block, CEO, Alberta Mental Health Board, stated that:
Case management also needs to be considered at a cross-jurisdictional level for those occasions when mental health patients from one jurisdiction need services while in another jurisdiction. Reciprocal arrangements relating to access and payment should facilitate their access to care as well as to the consistency and continuity of that care across jurisdictions. This would be a matter for discussion at a future federal/provincial/territorial Conference of Ministers of Health.
Moreover, numerous witnesses pointed out that many mental health services are provided in the community by providers other than physicians and are thus not covered under the Canada Health Act. This is particularly true for services provided by psychologists. In this context, Dr. Diane Sacks, President, Canadian Paediatric Society, told the Committee:
(…) currently, the majority of professionals who offer [cognitive behavioural] therapy are uninsured by most provincial health plans. There are trained, regulated professionals that, if society’s will was there, could treat many of our children and youth. (…) Having said that, there are professionals who can help make the diagnosis and treat these illnesses, but only if you have money, and lots of it. The waiting list to get the public school system or a community mental health centre to diagnose ADHD in
Toronto today is 18 months – that is two full school years. That is if you do not have money. If you happen to have $2,000, I can get you a psychologist within a week or two who will make a diagnosis and, if necessary, lay out for the school an extensive program to help your child succeed. Most employer-run insurance programs cover an average of only $300 for psychology. Most public programs cover zero.
In its brief, the Centre for Addiction and Mental Health (Toronto) stated that the Canada Health Act should apply to more than general hospitals and physicians and should include home care and prescription drugs prescribed outside of hospitals. In the view of the Centre, public funding for the cost of medications would make a tremendous improvement in the lives of many individuals with mental illness who require long term pharmacotherapy. For these individuals, access to medication is key to their ability to maintain employment, housing and the other community connections that support treatment and recovery.
Many witnesses supported the work already underway by First Ministers to expand home care to individuals with mental illness. They contended that any national home care program should encompass both mental illness and addiction.
Federal transfers to the provinces and territories for the purpose of health care are provided under the Canada Health Transfer (CHT). There has never been any, nor is there now, an identified, specific transfer to any province or territory dedicated to mental health care and addiction treatment. Currently, as a result of the 2003 First Ministers’ Accord on Health Care Renewal, the CHT provides funding for acute community mental health care, but no specific proportion of the transfer is expressly designed for this purpose.
The Mood Disorders Society of Canada recommended that federal transfer payments for the purpose of health care should have a portion dedicated specifically to the delivery of mental health care. The Society argued that two conditions should be attached to this funding: 1) provinces and territories should be prevented from reducing their spending on mental health care; 2) ongoing evaluations of provincial mental health care programs should be undertaken to ensure value for money.
Another proposal to raise revenue to support the treatment and prevention of addiction was made to the Committee. Called the “Behavioural Insurance Model”, this proposal is based on raising money for the purpose of addiction prevention and treatment through a certain dedicated percentage of revenues generated from behaviour associated with addiction (tobacco, alcohol, gambling).
The Ontario Federation of Community Mental Health and Addiction Programs informed the Committee that a Behavioural Insurance Model was introduced in 1999 by the Government of Ontario to fund an integrated array of services to address pathological gambling. Under this model, 2% of gross revenues from slot machines in provincial charity casinos and race tracks are dedicated to treatment, prevention and research. In 2002-2003, this formula generated approximately $36 million, an amount sufficient to support a comprehensive response to this serious problem.
In his brief, Dr. Wayne Skinner, Clinical Director, Concurrent Disorders Program, Centre for Addiction and Mental Health (Toronto), stated
(…) it is important to recognize that a number of behaviours that have addictive liability are regulated by the state, which also derives considerable tax revenue from them. This includes tobacco and alcohol, and more recently gambling. It has been estimated that more than half the revenues from alcohol and gambling come from 10 per cent of people who spend the most money on these activities. This 10 per cent population is the one at highest risk to being addicted to these behaviours. Given that over half of tax revenues from these behaviours are coming from that part of the population that is most vulnerable, government, if only from a crisis of conscience, should challenge itself to develop a proactive strategy toward the prevention, treatment and research of addictive behaviours and their mental health comorbidities. But beyond that, there is strong evidence that social spending to prevent and treat addiction and mental health problems provides an enviable return on investment. It is not unreasonable to expect that more of the revenues that behaviours with addictive potential provide be invested in helping people who are harmed by these behaviours.
In his submission to the Committee, Bill Cameron, Director General of the National Secretariat on Homelessness, stated that the NHI addresses mental health issues in two ways through 1) financial support for community initiatives and 2) partnership agenda on research.
The “Horizon Housing Society” is an example of community-based initiatives funded through the NHI; the Society acquired an apartment building in Calgary to be used as transitional housing for individuals with mental illness and addiction who are homeless or at risk of becoming homeless. The research agenda includes issues surrounding the availability and accessibility of mental health services for homeless people, the incidence of mental illness among homeless people and the causal relationship between deinstitutionalization and homelessness. Research under the NHI is also undertaken in partnership with CIHR.
According to Bill Cameron, many mental health services to homeless people end up being delivered in emergency departments. Moreover, the homeless population faces many barriers that impact their access to the mental health services they need. For example, many are unable to make health appointments, and their ability to access coordinated care is impaired by their lack of an address and/or place of contact. In particular, many women with serious mental disorders do not receive needed care, apparently because, in part, they are not perceived to have mental health problems and also because of a lack of services designed to meet the special needs of homeless women.
Mr. Cameron also identified other major gaps in community services and supports directed to the homeless population, including emergency housing, supportive housing, and community-based mental health services. According to Mr. Cameron, safe and affordable housing with individualized supports is a key factor in the in helping the homeless generally, but he stressed that this may not be enough for those with severe mental illness and addiction. Long term supporting facilities such as emergency shelters and supports and transitional housing are necessary to help the chronically homeless. There is also a need for preventative measures such as dedicated affordable housing for individuals discharged from psychiatric institutions and the provision of short term intensive support services to be available immediately to those discharged from acute care hospitals, shelters and jails.
Witnesses told the Committee repeatedly that Canada needs a national action plan on mental health, mental illness and addiction. Many countries have already adopted such a national mental health policy or action plan. For example, in 1992, Australia developed a national mental health strategy to improve the lives of individuals with mental illness; also in 1992, the United Kingdom developed an action plan in five key health areas, one of which was mental health, which established targets for improvement of the health of individuals with mental illness and to reduce the suicide rate; in 1999, the report of the US Surgeon General made a commitment to improve mental health within the United States.
Canada is currently characterized by a serious lack of leadership on mental health, mental illness and addiction which, in the view of many witnesses and the Committee, has created a large void: there is no focus on mental illness and addiction within health care reform initiatives; there is no clear delineation of roles and responsibilities of the various stakeholders. Phil Upshall, President, Canadian Alliance on Mental Illness and Mental Health (CAMIMH), stated:
The current status of mental illness and mental health in
Canada paints a very bleak picture, beginning with a large void in leadership. (…) no policies and very few processes exist to address mental illness and mental health at a national level in
Canada. There is no clear identification of the roles and responsibilities of the government players involved. One of the most significant barriers to securing a national action plan appears to be the division of powers between provinces/territories and the federal government for health and social services. This need not be a hindrance to developing a coherent approach that will meet the needs of Canadians equitably.
Many witnesses recommended a strong leadership role for the federal government in the development of a national action plan. The current lack of leadership, of course, has contributed significantly to the piecemeal approach of addressing mental illness and addiction, to the development of various models in different jurisdictions, resulting in duplication and waste of resources. For example, Dr. James Millar, Executive Director, Mental Health and Physician Services, Nova Scotia Department of Health, stated:
Nationally, we are not doing (…) well. Provinces, individually, have been struggling with providing appropriate services and developed various models from the Mental Health Commission of
New Brunswick to the
Alberta Mental Health Board. The federal government has not provided leadership in developing a national strategy.
Similarly, Dr. Sunil V. Patel, President, Canadian Medical Association, told the Committee:
Canada is the only G8 country without such a national strategy. This oversight has contributed significantly to fragmented mental health services, chronic problems such as lengthy waiting lists for children’s mental health services and mental health.
National leadership on mental illness and addiction is long overdue. The federal government can play a major role in collecting national data, supporting research and knowledge dissemination, and educating Canadians about mental health, mental illness and addiction. Many witnesses stated that the federal government has a key role in addressing the housing, income and employment needs of individuals with mental illness and addiction. Moreover, there is the direct role of the federal government in the provision of mental health services and addiction treatment to Aboriginal peoples, federal inmates, the veterans and members of the Canadian Forces, RCMP and federal employees.
While numerous witnesses favoured national leadership, it was stressed that progress can only be achieved by the federal government in close partnership with the provinces and territories. For example, Dr. Pierre Beauséjour, Senior Medical Advisor, Alberta Mental Health Board, stated:
While we agree that national leadership by the federal government for the development of a national action plan on mental illness and mental health is crucial, we will propose that building consensus on national mental health goals, standards and accountability is imperative and that provincial/territorial leaderships in mental health are as necessary as federal leadership in that regard.
We firmly believe that a result-oriented partnership approach, a clear redefinition of roles and responsibilities and a synergy of efforts between the federal government and the provinces/territories will be needed for the development and implementation of a national cross-jurisdictional policy framework on mental health.
Witnesses argued that the national framework must set standards for service delivery covering all aspects of mental health from prevention, promotion and advocacy through community-based services to inpatient and specialty services. It must also provide services throughout the lifespan and ensure clarity of roles and responsibilities along the continuum of care. In addition, because most mental illnesses have their roots in childhood and adolescence, there must be a new focus on child and adolescent mental heath. Child and adolescent mental health has been ignored for too long. We must deal with problems early at their root before serious damage is done. In addition to children and adolescents, population groups also identified as in need of urgent action include Aboriginal peoples, senior Canadians, federal inmates, women and landed immigrants.
Another priority area within a national action plan is suicide prevention. The fact is that Canada, unlike Australia, Finland, France, the Netherlands, New Zealand, Norway, Sweden, the United Kingdom and the United States, does not have a national suicide prevention strategy. Many witnesses who appeared before the Committee urged the federal government to work with the provinces/territories and relevant stakeholders in the development of such a strategy. According to Dr. Paul Links, Arthur Sommer Rotenberg Chair in Suicide Studies, countries that have implemented national strategies on suicide prevention have experienced reductions of between 10% to 20% in suicide rate. Moreover, the Centre for Suicide Prevention told the Committee that only two provinces – New Brunswick and Quebec – have implemented a suicide-specific prevention strategy. Witnesses urged the federal government to work with the provinces/territories and relevant stakeholders in the development of a national suicide prevention strategy.
A number of witnesses mentioned that there is an opportunity to coordinate a national mental health strategy with the National Drug Strategy. Given the high rate of concurrent disorders (mental illness and addiction), it is critical that links be forged between them. For example, national monitoring of the prevalence of substance use disorders through the National Drug Strategy would be of tremendous benefit to efforts to plan services for individuals with concurrent disorders.
Through the Canadian Alliance on Mental Illness and Mental Health (CAMIMH), some 20 NGOs representing individuals with mental illness/addiction, their families and service provider organizations have reached a consensus on the need for a national action plan on mental health, mental illness and addiction. This national action plan addresses four main areas: education and awareness; national policy framework; research; and surveillance:
· Public awareness campaigns and professional education in a wide range of social and medical courses can help reduce the stigma and discrimination that is associated with mental illness, addiction and suicidal behaviour.
· A national policy framework is required in terms of identifying and implementing best practices (for treatment, prevention and promotion) and planning human resources (psychiatrists, psychologists, psychiatric nurses, addiction specialists, social workers, etc.). National leadership is also necessary to develop a comprehensive cross-jurisdictional policy framework that can ensure equitable access to professional and community supports across the country.
· The federal government is best positioned to establish and support a national research agenda for mental health, mental illness and addiction. Priorities for research need to be identified, research funding needs to be increased, and the voluntary fundraising sector needs to be strengthened.
· A national surveillance system must be implemented to monitor accurately and evaluate the incidence and prevalence of mental illness and addiction (including suicidal behaviour). The information collected nationally could also be used to report on how well the system is meeting the needs of individuals with mental illness and addiction.
Many witnesses stressed that a national action plan for mental health, mental illness and addiction can only be developed through collaboration among the federal government, provincial and territorial jurisdictions, NGOs and other stakeholders including individuals with mental illness/addiction. In this context, the Schizophrenia Society of Canada stated:
It will take the work of all levels of government, working in concert with non-governmental organizations, to create and facilitate a national action plan. (…) Existing, capable agencies such as hospitals, professional associations and volunteer organizations that have been acting as band-aids in the current system are poised to be part of the mental health care solution in
Canada. The biggest challenge governments will face is coordinating a multi-tiered government system that was not designed to work together and integrating non-governmental organization into the system as a contributing partner. It is only through a concerted effort in these areas that Canada will witness a shift in mental health care that will effectively and efficiently treat and support individuals with mental illness and their families and reduce the burden to individuals, families and society caused by [mental disorders].
As stated by Phil Upshall, CAMIMH President, action must be taken now:
The time is now. (…) It has been fifteen years since the federal government released Mental Health for Canadians: Striking a Balance. Its policy document linked the national health promotion vision of “Achieving Health for All” to mental health. Other major reports, together with numerous provincial and regional policy and discussion documents have recommended significant changes to improve services and programs for: individuals with serious mental illnesses, children’s mental health services, suicide prevention, aboriginal peoples, and offender and prison populations. These reports continue to gather dust and Canadians continue to wait, as few of the recommendations and ideas have been implemented.
Overall, witnesses called for a commitment by all levels of government to act, to work together on developing common goals and on creating a cohesive, integrated national framework on mental health, mental illness and addiction. One overlooked element of federal government activity in this field appears to be its direct responsibility for over a million Canadians, some of whom are facing serious mental health issues.
Not only must the health care system treat mental illness (…) but
Canada needs to take proactive steps based on the broader health determinants to protect and preserve the mental health of its entire population, including those living with mental illness. Improving the social conditions that we know are necessary for overall good mental health (e.g. healthy physical and social environments, strong coping skills, along with health services) is essential to support positive mental health and recovery from mental illness.
[Canadian Mental Health Association, Brief to the Committee, June 2003, p. 3.]
Mental health, mental illness and addiction are strongly influenced by a wide variety of factors including biology and genetics, income and educational achievement, employment, social environment, and more. This fact points clearly to the need to address mental health, mental illness and addiction from a population health approach, a broad perspective extending well beyond health care per se.
The Committee heard repeatedly that treatment and recovery are difficult to achieve when basic needs for shelter, income and employment are not met. Many witnesses pointed out that it would be good public policy to take action to address these needs since access to housing, income and employment has been demonstrated to improve clinical status, reduce hospitalization, and enable individuals with mental illness to stay in their homes and communities. Access to housing, income and employment are also key to someone’s ability to participate in society and to enjoy the rights of citizenship free from stigma and discrimination.
Housing has been widely acknowledged as a priority in mental health policy at both the federal and provincial levels. What is needed now is action from both levels of government to implement new housing and supported housing programs based upon the foundation of existing policy and research that has shown convincingly that a diverse population of individuals with mental disorders can succeed in housing if appropriate supports are available. Appropriate housing and supports can substitute for long term inpatient care thereby decreasing society’s and affected individuals’ reliance on high cost hospital and institutional beds.
Access to adequate income and employment is another key determinant of health that must be a priority in any mental health strategy. Many individuals with mental illness must rely on government income programs, at some time during their illness, as their only source of income and access to prescription drug coverage. Unfortunately, many government income programs provide benefits that are too low, don’t cover realistic living costs, create barriers to employment, and are not flexible enough to respond to the episodic nature of mental illness. In addition, disability is often defined too narrowly for many individuals with mental illness or addiction to qualify. In Ontario, for example, provincial income support programs exclude individuals affected by addiction from the definition of disability altogether. These systemic barriers within government income support programs must be addressed to ensure that individuals with mental illness and addiction are able to access the basic supports that will help restore them to health and keep them well.
Support for employment is also a key area in which governments can do more. Individuals with a range of mental health problems can succeed in employment if flexible supports, responsive to their changing needs throughout treatment and recovery are available. Greater emphasis must also be placed on ensuring that individuals with mental illness are meaningfully accommodated in the workplace. Access to skills development, training and education must also be improved by encouraging academic institutions and other learning environments to accommodate more appropriately individuals with mental illness.
At present, the federal government has no comprehensive framework for mental health, mental illness and addiction federally or nationally. While several witnesses pointed to the fact that Canada stands alone among similar G8 countries in not having a national mental health policy reaching across the applicable jurisdictional boundaries, others noted the absence of an integrated framework even at the federal level with its responsibility for the provision of mental health services and addiction treatment to specific groups.
The lack of a federal framework may be primarily a function of inadequate collaboration, cooperation and communication among the various federal departments that have involvement in related or overlapping areas. However, it may also be a consequence of the difficulties of trying to address the multiple needs of very diverse populations. Whatever the reason, the Committee believes that despite its direct responsibility for the mental health needs of specific groups in the Canadian population, the federal government has made too little effort to coordinate its initiatives internally. In these areas, the federal government has both the right and the obligation to act and can do so without intensive (or even any) negotiations with other jurisdictions.
Similarly, the absence of an overall national framework may be attributed to some extent to the lack of clear role differentiation in these areas where provincial/territorial responsibility takes precedence. In general, the Constitution Act, 1867 gives the provinces power to legislate in the fields of health care, education, provincial jails, and the administration of the courts; while giving Canadian Parliament power over criminal law and procedure, as well as the management of penitentiaries. In addition to the power of criminal law, this leaves the federal government with two other potential constitutional powers when acting in a national capacity: its spending power; and the ability to pass laws for the peace, order and good government of Canada.
From both the federal and the national perspectives, it is obvious that the federal government’s role with respect to mental health, mental illness and addiction is not limited to the activities of the Health Canada. Related policies, programs and services fall in the broader social sphere as well as in the justice arena, outside the traditional health care sector. Other federal departments such as Human Resources Development Canada, Indian and Northern Affairs Canada, Veterans Affairs Canada, Correctional Services Canada, Justice Canada are among those that currently play a role in federal and national initiatives. And at the workplace level, Treasury Board as the employer of public servants has a major role to play in assisting its employees with issues related to mental health and addiction.
In looking at federal government activities with respect to the specific groups under its responsibility, there is little evidence to suggest the existence of strategies targeted at specific populations, let alone a broad all-encompassing federal strategy. No current efforts to develop an overall coordinated federal framework with collaboration by all involved departments or agencies are apparent. In most cases, there is little indication of thought being given to the development of a thorough and inclusive population specific strategy for addressing the mental health needs of any of the groups under federal responsibility. The provision of mental health services and addiction treatment and efforts toward mental health promotion and mental illness prevention remain highly fragmented, provided by numerous departments and departmental directorates. More collaboration would lead to a more integrated approach towards mental health. This would be an important step toward a policy based on population health.
The Committee also concurs with witnesses that better links are needed between the federal and provincial governments and among the various overlapping systems – health care, mental health, addiction, justice, social supports, etc.
Finally, it would also be important for the federal government to lead by example. If it is to play a leadership role in the development of a truly national action plan on mental health, mental illness and addiction, it must also show that it is willing and capable of providing mental health services to the populations for which it has direct responsibility. Clearly, there is a need to correct the ambivalent approach taken over the years by the federal government about the place of mental health in its policies and programs.
 The information contained in this section is based on the following five documents: 1) Leonard I. Stein and Alberto B. Santos, Assertive Community Treatment of Persons with Severe Mental Illness, New York, 1998; 2) World Health Organization, “Historical Perspective”, Section 3, in The Mental Health Context, Mental Health Policy and Service Guidance Package, Geneva, 2003; 3) World Health Organization, “Solving Mental Health Problems”, Chapter 3 in Mental Health: New Understanding, New Hope, Geneva, 2001; 4) Pamela N. Prince, “A Historical Context for Modern Psychiatric Stigma”, in Mental Health and Patients’ Rights in Ontario: Yesterday, Today and Tomorrow, published by the Psychiatric Patient Advocate Office, Ontario, 2003, pp. 58-60; 5) Canadian Mental Health Association, More for the Mind – A Study of Psychiatric Services in Canada, Toronto, 1963.
 The information contained in this section is based on the following nine documents: 1) Health and Welfare Canada, Mental Health Services in Canada, Ottawa, 1990; 2) .E. Appleton, “Psychiatry in Canada A Century Ago”, Canadian Psychiatric Association Journal, Vol. 12, No. 4, August 1967, pp. 344-361; 3) Elliot M. Goldner, Sharing the Learning – The Health Transition Fund: Mental Health, Synthesis Series, Health Canada, 2002; 4) Cyril Greenland, Jack D. Griffin and Brian F. Hoffman, “Psychiatry in Canada from 1951 to 2001”, in Psychiatry in Canada: 50 Years, Canadian Psychiatric Association, 2001, pp. 1-16; 5) Quentin Rae-Grant, “Introduction”, in Psychiatry in Canada: 50 Years, Canadian Psychiatric Association, 2001, pp. ix-xiii; 6) Henri Dorvil et Herta Guttman, 35 Ans de Désintitutionalisation au Québec, 1961-1996, Annexe 1 du rapport du Comité de la santé mentale du Québec intitulé Défis de la Reconfiguration des Services de Santé Mentale, 1998; 7) Julio Arboleda-Florez, Mental Health and Mental Illness in Canada : The Tragedy and the Promise, Brief to the Committee, 19 March 2003; 8) Paula Goering, Don Wasylenki and Janet Durbin, « Canada’s Mental Health System », in International Journal of Law and Psychiatry, Vol. 23, No. 3-4, May-August 2000, pp. 345-359; 9) Donald Wasylenki, “The Paradigm Shift From Institution to Community”, Chapter 7, in Psychiatry in Canada: 50 Years, Canadian Psychiatric Association, 2001, pp. 95-110.
 Greenland, Griffin and Hoffman (2001), p. 2.
 Hydrotherapy, which is also called the water cure, is a mode of treating diseases by the copious and frequent use of pure water, both internally and externally. Insulin coma treatment was a rarely used treatment of mental illness by means of hypoglycaemic coma induced by insulin.
 ECT is a procedure that consists in passing a small electric current through a region of the brain for a period of 1-3 seconds for the purpose of inducing neurochemical changes associated with the relief of psychiatric symptoms; the electrical stimulation also induces a brief seizure, whose appearance is modified by muscle-relaxing drugs. It generally lasts 20-30 seconds and then ends spontaneously. The patient is anaesthetized and asleep during the treatment and the seizure.
 This section is based on information provided in the two following documents: 1) Health Canada, “The Development of Alcohol and Other Drug Treatment in Canada”, in Profile of Substance Abuse Treatment and Rehabilitation in Canada, Ottawa, 1999, pp. 3-5; 2) Colleen Hood, Colin McGuire and Gillian Leigh, Exploring the Links Between Substance Use and Mental Health – A Discussion Paper, prepared under contract to Health Canada, 1996.
 John E. Gray, Margaret A. Shone and Peter F. Liddle, Canadian Mental Health Law and Policy, 2000, p. 5.
 In some cases, however, the patient may choose to have the court order the hospital to suspend treatment.
 John E. Gray and Richard L. O’Reilly, “Clinically Significant Differences Among Canadian Mental Health Acts”, Canadian Journal of Psychiatry, Vol. 46, No. 4, May 2001, p. 320.
 John E. Gray, Margaret A. Shone and Peter F. Liddle, Canadian Mental Health Law and Policy, October 2000, p. 358.
 Treasury Board of Canada, Canada's Performance 2003 – Annual Report to Parliament, Ottawa, 2004, p. 30.
 Tom Lips, Senior Adviser, Mental Health, Healthy Communities Division, Population and Public Health, Health Canada (11:6).
 The information contained in this section is based on a paper by Nancy Miller-Chenier, Federal Responsibility for the Health Care of Specific Groups, Parliamentary Information and Research Services, Library of Parliament, forthcoming.
 Correctional Service Canada, Brief to the Committee, April 2004, pp. 13-15.
 The Shepody Healing Centre (Atlantic region) with 40 beds; the Archambault unit (Quebec region) with 120 beds; the Regional Treatment Centre (Kingston, Ontario) with 149 beds; the Regional Psychiatric Centre (Prairie region) is a 194 bed facility linked to the University of Saskatchewan through a special agreement; the Regional Treatment Centre in Abbotsford (Pacific region) with 192 beds.
 Correctional Service Canada, Brief to the Committee, April 2004, p. 19.
 Federal-provincial Fiscal Arrangements and Established Programs Financing Act 1977, Chapter 10, 1977, Clause 27 subsection 8.
 Canada Health Act, 1984 (An Act relating to cash contributions by Canada in respect of insured health services provided under provincial health care insurance plans and amounts payable by Canada in respect of extended health care services) Chapter C-6, 1984, Clause 3.
 The CHST was established through separate budget bills tabled in February 1995 and March 1996. Its operation is governed by the Federal-Provincial Fiscal Arrangements Act.
 For more details on these federal programs, see William Young, Disability: Socio-Economic Aspects and Proposals for Reform, Current Issue Review 95-4E, Ottawa: Parliamentary Research Branch, 1997.
 Dr. Sunil V. Patel, President, Canadian Medical Association, Brief to the Committee, 31 March 2004, p. 3.
 Ray Block, CEO, Alberta Mental Health Board Brief to the Committee, 28 April 2004, p. 7.
 Dr. Diane Sacks, President, Canadian Paediatric Society (13:53-54).
 Centre for Addiction and Mental Health (Toronto), Brief to the Committee, 27 June 2003, p. 3.
 Acute community mental health care refers to acute care provided in the community to individuals with mental illness who have an occasional acute period of disruptive behaviour; the aim is to prevent or minimize recurrent institutionalization.
 Mood Disorders Society of Canada, Brief to the Committee, 12 May 2004, p. 7.
 Dr. Wayne Skinner, Clinical Director, Concurrent Disorders Program, Centre for Addiction and Mental Health (Toronto), Brief to the Committee, 2004, p. 6.
 Bill Cameron, Director General of the National Secretariat on Homelessness, Brief to the Committee, 29 April 2004, p. 1.
 See the Committee’s second report, Mental Health Policies and Programs in Selected Countries, for a full description of national mental health strategies in Australia, New Zealand, England and the United States.
 Phil Upshall, President, CAMIMH, Brief to the Committee, 18 July 2003, p. 7.
 Dr. James Millar, Executive Director, Mental Health and Physician Services, Nova Scotia Department of Health, Brief to the Committee, 28 April 2004, p. 3.
 Dr. Sunil V. Patel, President, Canadian Medical Association Brief to the Committee, 31 March 2004, p. 2.
 Dr. Pierre Beauséjour, Senior Medical Advisor, Alberta Mental Health Board, Brief to the Committee, 2003, p. 1.
 The following organizations have joined together to form the Canadian Alliance on Mental Illness and Mental Health: Autism Society of Canada, Mood Disorders Society of Canada, Canadian Medical Association, Canadian Health Care Association, National Network for Mental Health, Canadian Council of Professional Psychology Programs, Canadian Federation of Mental Health Nurses, Canadian Coalition for Seniors’ Mental Health, College of Family Physicians of Canada, Canadian Psychiatric Research Foundation, Canadian Association for Suicide Prevention, Canadian Association of Occupational Therapists, Schizophrenia Society of Canada, Canadian Mental Health Association, Canadian Academy of Child Psychiatry, Canadian Association of Social Workers, Canadian Psychiatric Association, Canadian Psychological Association, Native Mental Health Association of Canada.